Incident/Accident Form Co-Living

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 Hour Minutes AM/PM Option
Select if He/She is a

Resident
Exact Location of the Incident/Accident

Resident's Room Hallway Bathroom
Resident's Condition before the Accident

Normal Confused Disoriented
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
Name of Physician notified
Time Notified

: Hour Minutes AM/PM Option
Time Physician Responded

: Hour Minutes AM/PM Option
Name and relationship to the family member/resident representative notified
Time Notified

: Hour Minutes AM/PM Option
Time Responded

: Hour Minutes AM/PM Option
Was person involved seen by a physician?

Yes No
If yes, Physician's name
Where
Date & Time

Month Day Year
Date Hour Minutes AM/PM Option
Was first aid needed?

Yes No
If needed, type care of provided & by whom
Where
Date & Time

Month Day Year
Date Hour Minutes AM/PM Option
Was person involved taken to a hospital?

Yes No
If yes, hospital name
By whom
Date & Time

Month Day Year
Date Hour Minutes 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 *

Clear
Should be Empty: