FirstLight Incident Report
Please complete this form to report any accidents or incidents that occurred during your shift.
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Email *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Name of Client *
Name of Caregiver Reporting *
Location of Incident (Client's Address) *
Client Related Type of Incident
Personnel Related Incident
Security Related Issues
Description of Incident (Please provide as much detail as possible):
What actions were taken immediately after the incident? *
Was emergency medical services (EMS) contacted? *
Was a supervisor notified? *
If a supervisor was notified, what was their name and when were they notified?
Were there any witnesses to the incident? *
If yes, please provide names and contact information of witnesses.
What do you believe was the primary cause of the incident? *
Suggest any preventative measures that could be implemented to avoid similar incidents in the future.
Overall severity of the incident
Minor
Severe
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