Incident Report

Date of Incident:(Required)

Type of Service:(Required)

Program Site Location:(Required)

Incident Location Address:(Required)

INCIDENT/ALLEGATION INFORMATION

Incident/Allegation Date:(Required)

Date Reported:(Required)

Incident/Allegation Start Time:(Required)

Incident/Allegation End Time:(Required)

Reporter’s Name:(Required)

First Last

Email:(Required)

Supervisor's Email:(Required)

Did someone witness this incident?(Required)

Names and Contact Information for Witnesses:(Required)

Name of Individuals Involved:(Required)

INCIDENT TYPE

Choose as many selections relevant to the incident. (be sure that each checked issue identified is addressed in narrative)

Hold Command (Alt) Button when selecting options

Client’s Behavioral Issues

Mental Health/Substance Use(Required)

Medical Event(Required)

Were other individuals involved(Required)

PERSONS INVOLVED IN THE INCIDENT

Name

First Last

DOB

Gender

Injury Sustained if Any : Y/N

Name

First Last

DOB

Gender

Injury Sustained if Any : Y/N

Name

First Last

DOB

Gender

Injury Sustained if Any : Y/N

Name

First Last

DOB

Gender

Injury Sustained if Any : Y/N

NARRATIVE OF INCIDENT OCCURRENCE

1. Describe the incident and surrounding circumstance.(Required)

(Include antecedent/precipitating factors/behaviors of individuals involved. Provide facts and avoid ALL speculations)

2. Identify the actions taken by staff/guardian/clinicians to de-escalate the situation and ensure safety of individuals involved.(Required)

(Include individuals and entities contacted to resolve the situation (i.e. local authorities/governing bodies etc.)

3. Describe any follow up, corrective action and/or other relevant safety measurements taken or interventions put in place.(Required)

Completed By Signature(Required)

Date(Required)

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