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?
Guest Status Classification
Registered Hotel Guest
Day Visitor/Guest of Guest
Event Attendee
Staff Member
Contractor/Vendor
Trespasser/Unauthorized Person
Other
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?
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
Primary Incident Location Category
Guest Room/Suite
Bathroom (Guest Room)
Bathroom (Public)
Lobby/Reception Area
Corridor/Hallway
Elevator
Stairwell
Restaurant/Dining Area
Bar/Lounge
Swimming Pool Area
Fitness Center/Gym
Spa/Wellness Center
Parking Structure
Outdoor Walkway
Garden/Grounds
Beach/Pool Deck
Conference/Meeting Room
Kitchen/Back-of-House
Loading Dock
Other
Precise Physical Location Details - Floor, Zone, Landmark
Environmental Conditions Assessment at Time of Incident
Condition Type | Status/Measurement | Temperature (°C/°F) | Detailed Observations | |
|---|---|---|---|---|
Weather (if outdoors) | Clear/Cloudy/Rainy | 22 | No precipitation, light wind | |
Lighting Conditions | Adequate/Dim/Dark | 0 | Overhead lights functional, no obstructions | |
Floor Surface Condition | Dry/Damp/Wet | 0 | Recently mopped, no warning signs present | |
Air Quality | Normal/Poor | 0 | No visible smoke or odors | |
Noise Level | Quiet/Moderate/Loud | 0 | Normal ambient noise levels | |
Incident Category - Primary Mechanism of Injury
Slip, Trip, or Fall
Cut or Puncture Wound
Burn or Scald (Thermal)
Burn (Chemical)
Burn (Electrical)
Cardiac or Respiratory Distress
Neurological Event (Seizure, Stroke)
Allergic Reaction/Anaphylaxis
Food-Related Illness
Assault (Physical)
Assault (Sexual)
Equipment or Machinery Related
Motor Vehicle Incident
Struck By or Against Object
Overexertion/Strain
Poisoning or Toxic Exposure
Drowning or Near-Drowning
Animal or Insect Bite/Sting
Suicide Attempt or Self-Harm
Other
Detailed Narrative Description of Incident - Sequence of Events, Actions, and Observations
Body Parts/Injury Locations - Select All Affected Areas
Head/Scalp
Face/Eyes/Nose
Neck
Shoulder
Arm (Upper)
Arm (Lower)
Hand/Fingers
Chest
Back/Spine
Abdomen
Hip/Pelvis
Leg (Upper/Thigh)
Leg (Lower/Knee)
Ankle
Foot/Toes
Multiple Body Regions
Internal/Not Visible
Psychological/Emotional Distress
Other
Initial Severity Assessment - Rate Overall Injury Severity at Time of Discovery (1 = Minor, 5 = Life-Threatening)
Visible Injuries Description - Cuts, Bruises, Bleeding, Deformities, Loss of Consciousness
Immediate Actions Taken by Staff - Select All That Apply
Secured the Scene
Administered First Aid
Called Emergency Services
Notified Management
Comforted/Reassured Guest
Moved Guest to Safe Location
Applied Ice/Heat
Applied Bandage/Pressure
Elevated Injured Area
No Immediate Action Taken
Other
Was the incident scene secured and preserved immediately?
Were any photographs or physical evidence collected before scene was altered?
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?
Were external Emergency Medical Services (EMS) called or notified?
Type of Emergency Services Contacted
Ambulance/Paramedics
Fire Department
Police Department
Poison Control Center
Hospital Emergency Department Direct
On-Call Physician
Other
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 | |
|---|---|---|---|---|
Consciousness Level | Alert/Verbal/Pain/Unresponsive | AVPU scale assessment | ||
Pulse Rate | beats per minute | e.g., 72 bpm, regular rhythm | ||
Respiratory Rate | breaths per minute | e.g., 16 breaths/min, normal effort | ||
Blood Pressure | systolic/diastolic mmHg | e.g., 120/80 mmHg | ||
Oxygen Saturation | SpO2 percentage | e.g., 98% on room air | ||
Pain Level (0-10) | Numeric rating | Guest self-reported score | ||
Treatment Provided Log - All Interventions and Procedures
Treatment/Procedure | Time Administered | Administered By | Details and Guest Response | |
|---|---|---|---|---|
Cold Pack Application | Security Officer Smith | Applied to swollen ankle, guest reported relief | ||
Wound Cleaning with Saline | Front Desk Manager | Cleaned 3cm laceration, minimal bleeding | ||
Bandage Application | Front Desk Manager | Sterile gauze and tape applied | ||
Medication Administration Record
Medication Name | Dosage | Time Given | Administered By | Reason and Guest Consent | |
|---|---|---|---|---|---|
Acetaminophen | 500mg | Security Officer | Pain relief, verbal consent obtained | ||
Diphenhydramine | 25mg | Security Officer | Allergic reaction, verbal consent obtained | ||
Medical Equipment and Supplies Used - Select All
First Aid Kit (General)
AED (Defibrillator)
Oxygen Tank
Blood Pressure Cuff
Stethoscope
Thermometer
Glucometer
Splinting Material
Stretcher/Backboard
Neck Brace/Cervical Collar
Tourniquet
EpiPen
None Used
Was guest transported to medical facility?
Destination Medical Facility Name and Address
Did guest refuse medical treatment or transport against staff advice?
Did guest disclose any relevant medical history or pre-existing conditions?
Did guest disclose any known allergies (medications, food, latex)?
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 | |
|---|---|---|---|---|---|---|
Hotel Guest | Yes | Saw guest slip on wet floor near pool | ||||
Staff Member | Yes | Yes | Heard call for help, responded within 2 minutes | |||
Is CCTV or security video footage available for this incident?
Video Camera Coverage Details
Camera Location/ID | Footage Available? | Footage Quality | Reviewed? | Key Observations from Footage | |
|---|---|---|---|---|---|
Lobby Camera L-3 | Yes | High Definition | Yes | Clear view of guest entering lobby | |
Pool Deck Camera P-1 | Yes | Standard Definition | Not yet reviewed | ||
Were photographs taken of the scene, injuries, or conditions?
Was any physical evidence collected and preserved?
Were law enforcement or police notified?
Police Report Number (if applicable)
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.
Incident Classification - Risk and Severity Level
Level 1 - Minor (First Aid Only, No Liability Concern)
Level 2 - Moderate (Medical Attention, Potential Claim)
Level 3 - Major (Hospitalization, Likely Claim)
Level 4 - Critical (Life-Threatening, High Liability)
Level 5 - Catastrophic (Fatality, Maximum Liability)
Potential Liability Exposure Assessment (1 star = Minimal, 5 stars = Severe)
Is insurance notification required for this incident?
Is a legal hold or litigation hold required to preserve documents?
Is there a risk of media attention or public relations impact?
General Manager Review Date and Time
General Manager Name and Title
Management Actions Taken - Select All
Guest Account Adjusted/Comped
Formal Apology Letter Sent
Guest Relations Follow-Up Scheduled
Internal Investigation Initiated
Safety Inspection Conducted
Staff Retraining Scheduled
Equipment Repair/Replacement Ordered
Policy/Procedure Review Initiated
No Action Taken
Other
Risk Officer/Insurance Coordinator Review Date and Time
Risk Officer Name and Title
Risk Assessment Notes and Recommendations
Corrective Actions Required - Select All Priority Items
Immediate Safety Hazard Remediation (24 hours)
Short-Term Process Improvement (7 days)
Medium-Term Training Program (30 days)
Long-Term Capital Improvement (90+ days)
Vendor/Contractor Review
No Corrective Action Required
Follow-Up Action Items and Accountability Tracker
Action Item | Assigned To | Priority | Due Date | Status | Completion Notes | |
|---|---|---|---|---|---|---|
Inspect pool deck drainage | Maintenance Supervisor | Critical | Not Started | |||
Review wet floor signage policy | Housekeeping Manager | High | Not Started | |||
Staff retraining on emergency response | HR Training Coordinator | Medium | Not Started | |||
General Manager Digital Signature - Acknowledgment of Review and Accuracy
Risk Officer/Insurance Coordinator Digital Signature - Risk Assessment Confirmation
Form Completion Date and Time