Incident/Accident Form
Superior Co-Living
Full Name of Person Involved
*
First Name
Middle Name
Last Name
*
Adult
Male
Child
Female
Age
*
Date and Time of Incident/Accident
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Select if He/She is a
Resident
Exact Location of the Incident/Accident
Resident's Room
Hallway
Bathroom
Other
Resident's Condition before the Accident
Normal
Confused
Disoriented
Other
Select if He/She is a
Employee
Department
Job Title
Length of Time in this position
Select if He/She is a
Visitor
Other
Home Address
Home Phone
Occupation
Reason for Permission at this facility
Employee involved
Property Involved
Describe
Was this person authorized to be at location of incident/accident?
Yes
No
Describe exactly what happened and what the causes were. If an injury, state part of the body injured. If property or equipment damaged, describe damages.
*
Select the location of the injury/injuries down below with the image as reference
Cranial
Orbital
Frontal
Temporal
Nasal
Buccal
Cervical
Deltoid
Sternal
Pectoral
Axillary
Antecubial
Antebrachial
Umbilical
Mammary
Pectoral
Brachial
Lilia
Volar
Inguinal
Femoral
Patellar
Pedal
Parietal
Occipital
Scapular
Lumbar
Sacral
Gluteal
Perineal
Popliteal
Temp
Pulse
Resp.
B.P
Type of Injury
Laceration
Hematoma
Abrasion
Burn
Swelling
None Apparent
Other
Name of Physician notified
Time Notified
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Physician Responded
1
2
3
4
5
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name and relationship to the family member/resident representative notified
Time Notified
1
2
3
4
5
6
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Responded
1
2
3
4
5
6
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Was person involved seen by a physician?
Yes
No
If yes, Physician's name
Where
Date & Time
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Was first aid needed?
Yes
No
If needed, type care of provided & by whom
Where
Date & Time
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Was person involved taken to a hospital?
Yes
No
If yes, hospital name
By whom
Date & Time
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name, Title (if applicable), address & phone number of witness(es)
Additional comments and/or steps taken to prevent recurrence
Person preparing report
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: