TRNS Client Incident Report
Please use the following form to notify our clinical team of any client incidents you've documented in your EHR system in order to ensure the appropriate level of supervision as required by the BHA
Reporting Party Full Name:
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Incident Details
Please provide additional details regarding the incident at hand
Incident Type
Please Select
Breach of confidentiality
Death
Medical emergency
Abuse (physical, sexual, verbal, other)
Misappropriation of clients property
Date of incident
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reliatrax Client ID for the Client involved in this incident
Staff involved
First Name
Last Name
Phone Number
Please enter a valid phone number.
Additional witness
First Name
Last Name
Phone Number
Please enter a valid phone number.
Were the authorities involved or notified?
Please Select
Yes
No
Yes, case file or medical record was created
Give a full report of the incident including, dates, times, involved parties and any additional information obtained during this incident.
File Upload - Supplementary information (Photos, videos, or other materials)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What is the current status of this incident?
Please Select
Open - URGENT ATTENTION NEEDED
Open - Non urgent response needed
Resolved - Documenting incident
Submit
Should be Empty: