Incident Report Form

Name of Facility/Home:

Name of Person Directly Involved:
Resident? Employee? Visitor?

Select if address different from facility

Address:

City/State/Zip Code:

Phone:

Case Number (if applicable):

Other Persons Involved/Witnesses

Person 1:
Resident? Employee? Visitor?
Person 2:
Resident? Employee? Visitor?
Person 3:
Resident? Employee? Visitor?
Person 4:
Resident? Employee? Visitor?

Facts of the Incident

Date & time of Incident:

Name of Employee Assigned to Resident (if applicable):

Location of Incident (Kitchen, Yard, etc.):

Explain What Happened / Describe Injury (if any):

0 / 3000

Action taken by Staff / Treatment Given:

0 / 3000

Corrective Measures Taken to Remedy and/or Prevent Recurrence:

0 / 3000

Name of Treating Physician / Health Care / Medical Facility / Hospital:

Phone Number:

Date & Time of Care Given:

Physician's Diagnosis of injury, illness or Cause of Death, if known:

Person(s) Notified

Physician or RN (if applicable):

Notification Date / Time

Responsible Agency:

Notification Date / Time

Written Notice / Date

Designated Representative / Legal Guardian

Notification Date / Time

Written Notice / Date

Adult Protective Services (if applicable)

Notification Date / Time

Office of Recipient Rights (if applicable)

Notification Date / Time

Law Enforcement Agency (if applicable)

Notification Date / Time

Other (please specify)

Notification Date / Time

Does this incident meet any of the following criteria? *

Medical emergency
Police or EMS involvement
ULOA (Unauthorized leave of absence)
Abuse/Neglect allegations
Property destruction
Medication error with potential harm
Serious physical aggression
Self-harm
Environmental emergency
Unauthorized visitors
Other potential rights violations

Yes No

Signatures

Name and Title of Person Completing Report

ENTER SIGNATURE OF PERSON COMPLETING REPORT:
By entering your name and clicking "Submit", you acknowledge the above information is true and correct
to the best of your ability under penalty of perjury