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Incident Report Sample

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Incident Report Sample
INCIDENT REPORT FORM

|Submitted by | |
|Position | |
|Campaign/Department | |
|Immediate Supervisor | |
|Date of Submission | |

Details
|Date of Incident | |
|Location | |

Incident facts
Please provide a complete narration of events which transpired, including names of persons involved, time, date(s) and location. Please submit proof as necessary, such as recordings, documents, screenshots or the corresponding affidavit.

| |
|At around 10:30am two agents from RPA came at the clinic complaining of stomachache drooling of saliva and vomits after eating food|
|in the pantry with the menu for the day includes (inihaw na liempo, ube kakanin, ginisang amplaya and mishua soup. According to |
|them they ate their breakfast at around 8:00 am, the pork inihaw taste unusual and looks uncooked. I asked them if what is the food|
|last taken before manifesting the symptoms, if other agents ate at that time they must suffer the same thing, but according to them|
|they slightly feel dizzy only but subsides right then after an hour. Patients were given Buscopan and Ranitidine to relieve spasm |
|and pain to decrease acid accumulation due to vomiting
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