Urgent Incident Reporting: Guest Injury & Medical Emergency Documentation

1. Section 1: Guest & Room Metadata - Core Identification Details

Complete all guest identification fields with precision. This information is critical for medical, legal, and insurance correspondence. All fields marked mandatory must be filled before form submission.

Full Legal Name of Injured Person

Is the injured person the registered hotel guest?

Yes

No

Registered Guest's Room Number

Registered Guest's Name (if different from injured party)

Name of Registered Guest Host

Employee ID Number and Department

Contractor Company Name and Supervisor

Circumstances of Presence on Property

Specify Guest Status

Primary Contact Mobile Number

Email Address

Emergency Contact Name and Relationship

Emergency Contact Phone Number

Check-in Date

Scheduled Check-out Date

Total Number of Guests in Party

Loyalty Program Number (if applicable)

Has this guest been involved in any previous incidents on property?

Yes

No

Describe Previous Incident(s) - Date, Type, Resolution

2. Section 2: Incident Description & Environmental Conditions - Detailed Event Reconstruction

Provide a comprehensive, factual account of the incident. Include precise times, locations, and environmental factors. Objectivity is critical for risk assessment and legal protection.

Exact Date and Time of Incident

Date and Time Incident Was Discovered/Reported

Specific Room Number or Suite Identifier

Specific Public Bathroom Location

Specify Exact Location and Reason for Presence

Precise Physical Location Details - Floor, Zone, Landmark

Environmental Conditions Assessment at Time of Incident

	Condition Type	Status/Measurement	Temperature (°C/°F)	Detailed Observations
	A	B	C	D
1	Weather (if outdoors)	Clear/Cloudy/Rainy	22	No precipitation, light wind
2	Lighting Conditions	Adequate/Dim/Dark	0	Overhead lights functional, no obstructions
3	Floor Surface Condition	Dry/Damp/Wet	0	Recently mopped, no warning signs present
4	Air Quality	Normal/Poor	0	No visible smoke or odors
5	Noise Level	Quiet/Moderate/Loud	0	Normal ambient noise levels
6
7
8
9
10

Object Causing Cut/Puncture - Describe Item and Material

Heat Source - Temperature and Item

Electrical Source - Voltage and Equipment

Allergen Trigger and Exposure Pathway

Food Item Consumed and Time of Consumption

Assailant Description and Circumstances

Specify Incident Category and Mechanism

Detailed Narrative Description of Incident - Sequence of Events, Actions, and Observations

Head Injury Specifics - Laceration, Bump, Concussion Symptoms

Facial Injury Specifics - Cuts, Bruising, Dental Damage

Describe Psychological Impact and Guest Statements

Specify Body Part and Injury Details

Initial Severity Assessment - Rate Overall Injury Severity at Time of Discovery (1 = Minor, 5 = Life-Threatening)

scale_onescale_twoscale_threescale_fourscale_five

Visible Injuries Description - Cuts, Bruises, Bleeding, Deformities, Loss of Consciousness

Was the incident scene secured and preserved immediately?

Yes

No

Who Secured the Scene and Time Secured

Explain Why Scene Was Not Secured and Current Status

Were any photographs or physical evidence collected before scene was altered?

Yes

No

Describe Evidence Collected, Time, and By Whom

3. Section 3: Emergency Medical Response & Treatment Log - Professional Care Documentation

Document all medical response actions, treatment provided, and professional care administered. This section is critical for medical continuity and liability assessment.

First Responder Name and Role

Time Medical Response Was Initiated

Time Responder Arrived at Scene

Was a licensed medical professional (doctor, nurse, paramedic) on property at time of incident?

Yes

No

Medical Professional Name, Credentials, and Actions Taken

Were external Emergency Medical Services (EMS) called or notified?

Yes

No

EMS Agency Name and Contact Number

Explain Why EMS Was Not Called and Alternative Actions Taken

Time EMS Was Called/Notified

Time EMS Arrived on Scene

Time Guest Was Transported from Property (if applicable)

Medical Assessment - Vital Signs and Patient Status

	Assessment Parameter	Measurement/Value	Time Recorded	Notes/Context
	A	B	C	D
1	Consciousness Level	Alert/Verbal/Pain/Unresponsive		AVPU scale assessment
2	Pulse Rate	beats per minute		e.g., 72 bpm, regular rhythm
3	Respiratory Rate	breaths per minute		e.g., 16 breaths/min, normal effort
4	Blood Pressure	systolic/diastolic mmHg		e.g., 120/80 mmHg
5	Oxygen Saturation	SpO2 percentage		e.g., 98% on room air
6	Pain Level (0-10)	Numeric rating		Guest self-reported score
7
8
9
10

Treatment Provided Log - All Interventions and Procedures

	Treatment/Procedure	Time Administered	Administered By	Details and Guest Response
	A	B	C	D
1	Cold Pack Application		Security Officer Smith	Applied to swollen ankle, guest reported relief
2	Wound Cleaning with Saline		Front Desk Manager	Cleaned 3cm laceration, minimal bleeding
3	Bandage Application		Front Desk Manager	Sterile gauze and tape applied
4
5
6
7
8
9
10

Medication Administration Record

	Medication Name	Dosage	Time Given	Administered By	Reason and Guest Consent
	A	B	C	D	E
1	Acetaminophen	500mg		Security Officer	Pain relief, verbal consent obtained
2	Diphenhydramine	25mg		Security Officer	Allergic reaction, verbal consent obtained
3
4
5
6
7
8
9
10

Was guest transported to medical facility?

Yes

No

Reason for No Transport and Discharge Instructions Provided

Destination Medical Facility Name and Address

Did guest refuse medical treatment or transport against staff advice?

Yes

No

Refusal Details - Time, Witnesses, and Exact Wording of Refusal

Did guest disclose any relevant medical history or pre-existing conditions?

Yes

No

Medical History Disclosed

Did guest disclose any known allergies (medications, food, latex)?

Yes

No

Allergies Disclosed

4. Section 4: Witness Statements & Video Footage Summary - Evidence and Corroboration

Thoroughly document all witnesses and available electronic evidence. This section supports incident verification and protects all parties through objective documentation.

Total Number of Witnesses to Incident

Witness Details and Statement Summary

	Witness Full Name	Contact Phone/Email	Witness Type	Present During Incident?	Formal Statement Provided?	Statement Summary or Key Observations
	A	B	C	D	E	F
1			Hotel Guest	Yes		Saw guest slip on wet floor near pool
2			Staff Member	Yes	Yes	Heard call for help, responded within 2 minutes
3
4
5
6
7
8
9
10

Is CCTV or security video footage available for this incident?

Yes

No

Video Footage Description - Camera Angles, Coverage, and Key Visual Evidence

Explain Why Footage Is Not Available

Video Camera Coverage Details

	Camera Location/ID	Footage Available?	Footage Quality	Reviewed?	Key Observations from Footage
	A	B	C	D	E
1	Lobby Camera L-3	Yes	High Definition	Yes	Clear view of guest entering lobby
2	Pool Deck Camera P-1	Yes	Standard Definition		Not yet reviewed
3
4
5
6
7
8
9
10

Were photographs taken of the scene, injuries, or conditions?

Yes

No

Photograph Documentation Log

	Photo Description	Time Taken	Taken By	File/Photo ID Number
	A	B	C	D
1	Injury to guest's right ankle		Security Officer	IMG_2025_001
2	Wet floor condition near pool		Front Desk Manager	IMG_2025_002
3
4
5
6
7
8
9
10

Was any physical evidence collected and preserved?

Yes

No

Physical Evidence Chain of Custody

	Item Description	Location Found	Time Collected	Collected By	Storage Location
	A	B	C	D	E
1	Broken glass fragment	Lobby floor near vase		Security	Evidence Locker A-3
2	Wet floor sign	Pool deck		Manager	Storage Room B
3
4
5
6
7
8
9
10

Were law enforcement or police notified?

Yes

No

Police Department Name and Officer Badge Number

Reason Police Were Not Notified

Police Report Number (if applicable)

5. Section 5: General Manager & Risk Officer Sign-Off - Management Review and Risk Assessment

Final management review, risk classification, and sign-off. This section authorizes official incident closure and triggers any necessary follow-up actions, insurance notifications, or legal holds.

Potential Liability Exposure Assessment (1 star = Minimal, 5 stars = Severe)

starstarstarstarstar

Is insurance notification required for this incident?

Yes

No

Insurance Company Name and Policy Number

Is a legal hold or litigation hold required to preserve documents?

Yes

No

Legal Hold Instructions - Scope, Custodians, and Preservation Requirements

Is there a risk of media attention or public relations impact?

Yes

No

PR Risk Assessment and Recommended Communications Strategy

General Manager Review Date and Time

General Manager Name and Title

Risk Officer/Insurance Coordinator Review Date and Time

Risk Officer Name and Title

Risk Assessment Notes and Recommendations

Follow-Up Action Items and Accountability Tracker

	Action Item	Assigned To	Priority	Due Date	Status	Completion Notes
	A	B	C	D	E	F
1	Inspect pool deck drainage	Maintenance Supervisor	Critical		Not Started
2	Review wet floor signage policy	Housekeeping Manager	High		Not Started
3	Staff retraining on emergency response	HR Training Coordinator	Medium		Not Started
4
5
6
7
8
9
10

General Manager Digital Signature - Acknowledgment of Review and Accuracy

Risk Officer/Insurance Coordinator Digital Signature - Risk Assessment Confirmation

Form Completion Date and Time