Incident Report

1) Person's Name:
2) Incident Date:
3) Incident Time:
4) Incident Location:
5) Incident Type: (check all that apply) Note: Medication Errors must be filed using the medication error report form
Behavioral (No Behavioral Plan)
Injury
Alleged Abuse
Physical Aggression
Fall
Other (specify)
Hospital / Urgent Care Visit
Hospital Name:
Admitted: Yes No Decision Pending
6) Witnesses:
7) Relevant Details Leading Up To Incident:
8) Incident Details:
9) Post-Incident Follow Up:
10) All Staff working at time of Incident:
11) All individuals present at time of Incident:
12) Nurse Notified:
Yes (All medically related incidents require nurse notification.)
Name:
Date:
Time:
13) Supervisor Notified:    Date:    Time:
14) Name of Reporting Employee: