CQS, CQR, QAC/B & A Incident Report_

  • Incident Report

  • Please select the group at the time of the incident:*
  • What type of report are you submitting?*

  • Here are the policies related to this form:

    Accident & Incident Reporting Policy        Student/Participant Abuse Policy     

    Restrictive Use Policy

     

  • Date of incident:*
     - -
  • Rows
  • Rows
  • The issue took place:*
  • Type of incident:*
  • Date the issue occurred:*
     - -
  • Start Date:*
     - -
  • End Date:*
     - -
  • Members of public involved?*
  • Observation Length
  • Has the Principal or Program Director been notified of this concern in accordance with the Student/Participant Accident & Incident Reporting, Abuse, and Restrictive Use policies?
  • Was a physical injury observed?
  • Were any staff members injured?
  • Emergency contacts notified?*
  • Which room did you use?*
  • How would you describe the severity of this incident?*
  • Parents/guardians notified?*

  • Describe the incident

  • Were emergency services required?*
  • Was a PRN (pro re nata - as needed) administered*

  • The student/participant's medication administration record (MAR) must be completed. 

  • Was First Aid administered?*
  • Consciousness*
  • Breathing:
  • Did you call for help
  • Was the casualty transported to another location for treatment such as a hospital or walk-in-clinic?*
  • Did you contact a parent/guardian/ emergency contact?*
  • Were you the First Aider*
  • Date of submission
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: