Name *

First

Last

Date *

Time *

Location of Incident: *

Your Relation *

• Employee
• Client
• Witness
• Family Member
• Other

If Other: Who?

Name(s) of Individuals Involved:

Fall -Type of Incident

• No obvious injury
• Minor Injury
• Major Injury

Aggression -Type of Incident

• Verbal
• Physical
• Sexual

Choking -Type of Incident

• Choking

Other (specify)

Mobility -Client Status

• Ambulatory
• Wheelchair
• In bed

Condition -Client Status

• Oriented
• Disoriented
• Agitated
• Sedated

Safety Devices -Client Status

• Walker
• Cane
• Other

Type of Injury

• None obvious
• Abrasion
• Bruise
• Burn
• Laceration
• Needle stick
• Puncture
• Sprain/strain
• Fracture

Other Type of Injury

• Act/Theft
• Client Abuse/Neglect
• Unsafe Conditions
• Fire/Life Safety
• Staff or Visitor Injury
• Workplace violence
• Confidentiality Concern/violation
• Property/Equipment Damage

Other (specify)

Other People Involved

• Staff
• Family member
• Friend
• Neighbor

Injury:

• None obvious
• Minor
• Major

Details of incident:

Describe incident: Where and when did it occur, who was there, what happened, what caused it, what was done to resolve the situation.

Follow up by supervisor – describe who was spoken to, what was done by those involved, actions taken as a result of incident

Signature *

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