Incident Report Form

* = Required Information

Date of Incident *

Time of Incident *

Exact Location of Incident *

Name of primary resident involved (leave out names of other residents) *

Name of the site/house where the primary resident resides (ie. 778 Blair, 2446 15th, 2527 14th, 3223 14th,
etc.)

Name(s) and title(s) of staff present and/or Involved *

Name and Title of Staff Person completing Incident Report. *

Type of Incident (Check all that apply.)

Individual(s) verbally notified of incident within 1 hour of the incident (includes voicemail)

Did the incident involve a Manual Hold of the Client? If "YES" STOP here, and complete a EUCP (Emergency Use of Controlled Procedure) Report.*

Yes

Witness(es) to incident - Please do not include other client names, instead use: Person #1, Person #2, etc.

If property was destroyed/ damaged, please describe

If Medical Attention was required, please describe:

If the person is prescribed a PRN psych med, was it offered? *

No PRN prescribed

Not applicable for this incident

PRN offered - Refused by client

PRN offered - Accepted by client (A PRN Actual Use Form Is REQUIRED)

Please describe what led up to the incident and/or what happened just prior to the incident occurring.

Please describe, with attention to detail, what happened.

Please describe what efforts staff made in an attempt to avoid or minimize the severity of the incident. *

Please describe the staff response to the incident and/or how the incident was resolved. *

Please describe any follow up needed to fully resolve or prevent recurrence of the incident.

Date Report Completed *

Time *

The following individuals were provided the preceding Incident Report via e-mail (or US mail if no email)

Date Sent*

Time Sent *

Pattern Noted

Yes

If pattern noted, please describe the plan to reduce likelihood of recurrence.

First

Last

Date