Incident Report

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Incident Report

This form must be completed immediately after any incident.

Incidents include (but are not limited to):
• Falls
• Injuries
• Refusal of care
• Medical emergencies
• Aggressive behavior
• Equipment or safety issues

If internet access is unavailable, report the incident by phone and submit this form as soon as access returns.

Caregiver Name *

Caregiver ID or Phone Number *

Client / Resident Name *

Client Type *

Home Client

Facility Resident

Facility Name *

Date of Incident *

YYYY

Time of Incident *

Time

Type of Incident *

Fall

Injury 2

Refusal of care

Medical emergency

Aggressive behavior

Equipment / safety issue

Other

Description of Incident

Describe what happened, where it occurred, and who was present.

Immediate action taken *

Client assisted / made safe

Supervisor notified

Family notified

EMS / Ambulance called

Incident documented

No action required

Was anyone injured? *

Yes

If Yes,

Injury details

Was the client transferred to hospital? *

Yes

If Yes

Hospital / Facility Name

Supervisor Notified? *

yes

Additional notes

Any follow-up needed or additional details.

Submit

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