Critical Incident Report

This evaluation form is to be completed following an incident.
Incident name:
Date of incident:
DD slash MM slash YYYY
Location of incident:
Critical incident team leader:
Brief description of incident that occurred
1. What action was taken to address the incident, including follow up action?
2. Please identify any issues that may have contributed to, or caused the incident
3. What steps could be taken to reduce the risk of the incident occurring again?
4. Please identify ways in which the response to the incident could be improved.
Report completed by :
Name & Title :
Date
DD slash MM slash YYYY
Signature
ADMIN ONLY
Improvements suggested (Q3 & 4)?
- NA
Initial :
Date
DD slash MM slash YYYY
If yes:
Added to Feedback Register?
- NA
Initial :
Date
DD slash MM slash YYYY
Added to Feedback Register?
- NA
Initial :
Date
DD slash MM slash YYYY