ANONYMOUS INCIDENT REPORT

At Life Changes, Inc. we take the care and safety of both our residents and our team seriously. We understand, at times, you may want to report on misconduct of another person but do not want to suffer any repercussions. For this reason, you may use this tool to submit an anonymous incident report. There is a place for your name and contact information should you choose to have management contact you, but rest assured, this report will remain confidential. Entering your name is not required to submit this form. Please be as concise as possible when completing this Incident Report.

Date of Incident

Date

Time of Incident

Hour Minutes

AM/PM Option

Location of Incident

Were there other witnesses who may be willing to come forward?

Who were the witnesses? (Please only provide this info if the witness is willing to have his or her name disclosed.)

What happened? Be as detailed as possible.

Your Name

Your Name is NOT Required

Phone Number