EMPHN Employee Internal Incident Form

This is the form to log incidents.

If this is feedback (for example compliments, feedback, suggestions or complaints) then please use the Feedback form.

Please ensure all relevant information is entered. Mandatory fields are marked with a red arrow.

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Please enter your Provider / Contractor name - as applicable

Please enter your contract number with EMPHN (if known)

Please select the most appropriate incident type

Please provider details of Incident type

Please select if this a people or other business incident (for example: Fire, theft, computer system crash).

Please select from the list at what stage in the service delivery the incident occurred

If you have selected other, please provide details.

Please provide a brief deidentified report of the incident
Details of Persons Involved or details of any witnesses
Please enter all the relevant details of the persons involved. Please use the "add another" button for each extra person.
1

Please select one

Please select the age of the client. This is not mandatory however may assist resolution of the issue.

Please indicate title of person involved

Please enter the persons name, if they do not wish to be identified (i.e. for privacy reasons) please list their initials

Please select one

Please enter best contact details (phone number, email, etc.), so EMPHN can provide follow-up if appropriate

Please provide details of any steps or actions already taken, apart from first aid care. This should include steps to remove the hazard or preventing it happening again.

If no actions have been taken, please indicate this by typing none.

Please enter a date as to when these steps were taken

Thank you!

Thank you for completing this form. Please press submit to send this to our system. If you wish to add an evidence document please do so on the following page. Don't forget to keep a PDF copy for your records.

Attach Evidence Documents

Add another Document