Question

Fill out the incident form

Work Incident Report: Situation On Friday. September 5 Beniamin Frariyn accidently tipped over omputer cord. He fel and hit ris head on Molly's desk and ehow twisted his ankle. His lower ip was bleeding due to biting through it when he fell. Benjamin was taken into the clinic treatment t and given 3 stitches in his lower ip and an ice pack for his ankle. The doctor on staff that day didn't think he had a concussion and advised him to go home: keep his ankle elevated above his heart and apply ice. days. He was also advised to get the stiches out in 10 As you use the above information to complete the attached incident report: keep in mind the tolowing: 1. What information is missing 2. How would you go about obtaining the missing information? 3. Can other read your handwriting? 4. How soon does this form need to be submitted to your supervisor? Injury Incident Report Form be completed by stuff within 12 hours of incidentacciden Incident Time ncident Date: injured Person Name Phone Numbers Male/Female Date of Birth Details of Incident Who was injured person? Injury Type: Does Injury require Hospital/Physician? Yes: Hospital Name: Address Hospital Phone Numbers njured person/Party Signature/Date Important Notes and Instructions: Prepared By Date: Incident Report Template

Answer 1

1 Incident date-September 5th

Incident time-NA

Injured Person Name-Benjamin Franklyn.

Address-NA

Phone No-NA

Male

Date of Birth-NA

Details of Incident-On September 5th Benjamin Franklyn tripped over and hit his head on a desk and somehow during his fall,twistedhis ankle.His lower lip has been bleeding ,as he bit through it during his fall.

The injured person was Benjamin Franklyn.

Injury type-Moderate injury.

Yes ,he required the assistance of the physician.

Hospital Name-NA

Address-NA

Hospital Phone Number-NA