Sample Medical Incident Report
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1
2Airline
SAMPLE MEDICAL INCIDENT REPORT
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(To be completed for all incidents)
COMPLETED FORM TO BE RETURNED TO:
NAME OF PERSON
COMPLETING FORM:
Staff ID:
SECTION 1
Date:
/
/
Flight No:
From:
To:
PATIENT DETAILS
(Complete as applicable)
Name:
Sex:
M / F
Age:
Seat No:
Frequent flyer member?
Y/N
Home Address:
DETAILS OF ILLNESS / ACCIDENT
Time/Date of Onset (GMT):
:
hrs.
/
/
Location:
Describe events leading up to incident:
SYMPTOMS & SIGNS
(tick, circle or complete all appropriate boxes)
Site(s):
Severity:
Mild / Moderate / Severe
PAIN:
Character:
Sharp / Cramping / Aching / Throbbing
Pattern:
Constant / Variable
BLEEDING
Site(s):
Severity:
Mild / Moderate / Severe
Nausea
Vomiting
Diarrhoea
Cough
Breathless or wheezy
Faint
Pale
Blue
Flushed
Clammy/Sweating
Hot/feverish
Cold
Dizzy
Weakness
Fit/Convulsion
Anxious
Confused
Aggressive
Intoxicated
Rash/spots
Where:
Other (specify):
INJURY
(tick appropriate box/boxes):
Abrasion
Amputation
Fracture
Bruising
Burn
Concussion
Cut
Dislocation
Sprain
Foreign Body
Body Part
Head/neck
Eye
Ear
Torso
Back
Arm
Hand
Finger
Leg
Foot/toe
Pulse:
/ minute
Blood Pressure:
mm/Hg
OBSERVATIONS:
Temperature:
Respiration:
/ minute
Other observations:
cut-off-portion
TRANSFER OF CARE TO GROUND MEDICAL SERVICES
Name of Casualty:
Date and time of onset:
Brief Details of Incident:
Oxygen given:
YES / NO
If yes, did condition improve?
YES / NO
Was casualty unconscious at any time?
YES / NO
Defibrillator applied?
YES / NO
If yes, were any shocks given?
YES / NO
MEDICATION ADMINISTERED:
Drug:
Dose:
Time (GMT)
Any other treatment given:
Crew Member name (CAPITALS):
Staff ID:
Signature:
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