Incident Report Form
 
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Consumer Information
Consumer Full Name: *
Consumer Date of Birth:
MM
/
DD
/
YYYY
Consumer Address: *
Consumer City: *
Consumer County: *
Incident Information
Date of Incident: *
MM
/
DD
/
YYYY
Time of Incident: *
Time
:
Location of Incident: *
Description of Incident: *
Please give a detailed description - (Who, What, Where, When)
Description Cont'd  (Check any that apply):
Self-harm
Provider harm
Hit/Punch
Bite
Kick
Scratch
Cut
Other
Injury Information
Please provide a thorough description of any Injuries that have occurred
Injury - Describe Type and Location: *
Body Part Injured  (Check any that apply):
Left-Side
Right-Side
Head or Face
Mouth / Teeth
Hands / Arms
Feet / Legs
Neck or Chest
Abdomen
Back / Buttocks
Genitals
None
Immediate Action to Ensure Health & Welfare of Individuals: *
Notification Information
Your Full Name: *
Witnesses to Incident: *
Only Authorized Staff Should Inform Parents of Incidents
Please choose the authorized Ability Matters staff member you contacted about this incident
Staff Member You Contacted (via phone, email or text): *
Time You Notified Authorized Staff Member: *
Time
:
Name of Parent or Guardian (this is listed on the consumer's emergency contact sheet): *
IR Type Description Mapping
BX: Behavioral
MED: Medication
MUI: Major Unusual Incident
IR Type *
Housing or Day Service? *
Consumer House *
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