Incident Report

Date:___________________________Time:___________________________Place:_______________________

If not a Resident, Status of Person Involved:

Visitor:___________________ Employee:____________________ Other:___________________

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Last Name, MI, First Name Account/Employee ID No.

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Address City State Zip

Description of incident by person involved:_______________________________________________

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Description of incident by witness:_________________________________________________________

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Name of Witness:____________________________________________________________________________

Address:______________________________________________________________________________________

Describe nature and extent of apparent injury:___________________________________________

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Emergency Treatment given:_______________________________________________________________

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Was an ambulance called: Yes:___________ No:_____________ Time:_________

Name of ambulance called:__________________________________________________________________

Hospital transported to:_____________________________________________________________________

Was a Physician called: Yes:___________ No:_____________ Time:_________

Physician’s Report:___________________________________________________________________________

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Doctor’s Signature

Remedial measures to prevent similar incident:__________________________________________

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Date of Report:_______________________________ Time:_________________________________

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Staff Member’s Signature making report Title

Clinical Director’s
Comments:_______________________________________________________________

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Specific Incidents Leading to Discharge:

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Client Remarks:

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List of resources given to client for other treatment;

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Client Signature Staff Signature