Incident Report

Incident Report
INCIDENT DEFINITION:
Any event which is not consistent with the routine operation of CAPS and that adversely affects or threatens to affect the well-being of the employees, volunteers, patients, students, visitors, casual workers, or property of CAPS regardless of whether an actual injury is involved or not.

All Incidents will be reviewed in relevant department meetings and Quality Improvement Meetings. The Incident Report should be completed in a timely manner by the personnel who first witnessed or discovered the incident or by the personnel most closely involved in the occurrence.
Reported By*

First NameLast Name
Date and Time of Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Incident*
Affected Party*

PatientEmployee/VolunteerVisitorProperty
Affected Party Name or Initials/Case #*
Case #*
Name and Phone Number of Witnesses*
Incident Description*
Possible Contributing Causes
Action Taken by Person Reporting Incident*

Employee Supervisor NotifiedAuthorities NotifiedEquipment Removed for ServiceAffected Party Sent for Medical CareOther
Corrective Action Taken
Recommendations to Prevent Future Incidents
Signature of QIC Member

Clear
Date

MonthDayYear
Date
Should be Empty: