Incident Report

Incident Report - General

To report an incident, please provide the following information
Report date and time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date and time when incident occurred:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Person Completing Incident Report:*

Mr/Ms/MrsFirst NameMiddle NameLast Name
Role of person completing report*
Name of Client Involved (if more than one client include other clients info in the incident details box)*

First NameLast Name
Client Type

Private PayMedicaid WaiverBCHD ClientNot SureOther
Name of Caregiver or Staff Involved (if more than one caregiver or staff, include additional info in the incident details box)*

First NameLast Name
Type of Incident Being Reported (select all that apply)*

Alleged AbuseAlleged NeglectBehavioralCaregiver Illness / InjuryClient HospitalizationFireProperty DamageSuspected TheftCar AccidentHousehold AccidentSelf AbuseInjuryDeathNo Call / No ShowLeave w/NotificationLeave w/o NotificationSuspension of ServiceEnd of ServiceDeath of ClientCaregiver Unprofessional BehaviorFallRefusing ServiceClient No Show / UnavailableClient Late CancellationOther
Type of Injury Sustained, if any:*

ScratchLacerationBruiseBiteSwellingNoneOther
Body Parts Injured, if any:*

Head or FaceMouth or TeethHands & ArmsFeet or LegsNeck or ChestAbdominal PainBack or ButtocksGenitalsNoneOther
Place of Occurrence*

Client HomeDay ProgramBusinessOff WorkOther
Incident details (please provide additional details about the incident)*
Briefly describe status of individual at time of report:
Upload Any Relevant Files / Documents:

Cancelof
If incident was reported to law enforcement, please provide report no;, name of officer and government agency. If not, please enter "Not applicable"*
Describe an action(s) taken to address or resolve incident.
Attestation*

I certify that the above information is true and correct.
Signature*

Clear
Should be Empty:

Incident Report - General