DCIQ: Once for Wales Concerns Management System Incident Reporting Form (V4A)***Logged Out Reporting Form***

Who was affected?

Incident date (dd/mm/yyyy)

Time (hh:mm)

Reported Date

Incident Service

Location of Incident

Exact location

Reporter's initial harm assessment

This incident is graded on potential harm caused by the Health Body
The All Wales Grading Framework is part of the PTR Regs. For a copy of the framework please click here

Does this incident need external reporting?

Certain incidents and events are reportable to external agencies, NHS Wales Executive, Welsh Government, Health and Safety Executive (HSE) Including RIDDOR, Medicines Healthcare Regulatory Agency (MHRA), Never Events and SMTL.

Description

Please provide a brief description of any immediate action taken. Please provide a brief description of the incident ensuring that no identifiable information is included in this box.
Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP

Brief Description of actions taken

Please provide a brief description of any immediate action taken, ensuring that no identifiable information is included in this box.
Please DO NOT put: Names, Hospital/NHS Number, Date of Birth, Acronyms eg GP, HV, DN, BP

Vehicle Registration Number

Where a vehicle was involved in the incident

Booking or CAS Number if applicable (WAST)

Laboratory Specimen Number

Classification

Category

Sub Category

You have selected 'Other' - Please tell us what Sub Subtype option is missing from the system

Fire Additional Options

Fire alarm activation: Additional Options

Was a ligature used?

Method violence and aggression was received by

Has a Perpetrator been identified?

Please provide as much information that is known about the perpetrator

e.g. description of perpetrator

Was any equipment involved in the incident?

Did medication have a direct impact on this incident?

Was a controlled drug involved?

Does this incident have Information Governance considerations?

The answer should be 'yes' if the incident involves personal or sensitive data, including near misses. For example, a breach of confidentiality, theft, loss or misuse of personal data, information security, etc. For further advice, please contact your information governance team

Does this incident have any safeguarding elements?

If yes, what process(es) were or will be followed?

Is this Incident Related to Coronavirus/COVID-19?

Is this related to Industrial Action?

Date of Industrial Action

Further information pertinent to Industrial Action

Is this incident about nursing care?

This relates to the NHS Wales Nurse Staffing Act and appropriate staffing level and skill mix

IPC antigens

Was any other contact involved in the incident?

Is this incident highly confidential (not for circulation)?

This may include highly confidential information (staff / service user / patient) which requires restricted access. This may include Freedom to Speak Up Safely

Who have you informed of the incident?

Please select which 'Other NHS Body' has been informed

Are there any documents to be attached to this record?

Contact Role

Forenames

Surname

Work Telephone Number

Reporters Location

This would be your usual place of work

Reporters Service

This would be Service/Dept in which you work/are employed

Incidents

Once for Wales Concerns Management System

Incident Reporting Form (V4A)

Logged Out Reporting Form