My CareTaker Incident Report

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My CareTaker Incident Report

Email *

Record my email address with my response

Employee Name *

Employee Phone
*

Participants Full Name
*

Participants Phone

Incident Relates To
*

Date & Time of Incident
*

Time is in 24-hour format

YYYY

Time

Location of Incident
*

Type of Incident:
*

Abuse (e.g. financial, physical, rights)

Behavioural (e.g. verbal abuse, inappropriate sexual behaviour)

Fall

Property Damage (e.g. broken vacuum)

Medical Episode

Missing Items / Theft

Near Miss

Other:

Details of Incident
*

Details of Injury (if applicable): Nature of Injury (e.g. burn, cut, bruising, sprain)Location on body (e.g. back, left forearm)

Insert Type of Injury : if applicable (if No any injury then Type NO)

Immediate Action is Taken *

Tick the box which applies

Contacted Office

Applied First Aid

Called Emergency Services for Assistance

Contacted Next of Kin / Primary Contact

Person Requested No Action Taken

Required

Outcome of Immediate Action Taken

Next of Kin / Primary Contact to attend to person

Person declines further assistance

Person transferred to hospital

Incident report done

Any other Details:

Write if you have anything to say Otherwise leave it blank

A copy of your responses will be emailed to .

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