CQS, CQR, QAC/B & A Incident Report

Incident Report
Please select the group at the time of the incident:*

Calgary Quest School (CQS)Calgary Quest Resources (CQR) - Centre for OpportunityQuest Adventure Camp/Before and Aftercare
What type of report are you submitting?*

Incident ReportFirst Aid ReportSafeguarding Report
Here are the policies related to this form:

Accident & Incident Reporting Policy Student/Participant Abuse Policy

Restrictive Use Policy
Your name:*

First NameLast Name
Date of incident:*

MonthDayYear
Date
Location where incident occurred:*
Incident start time:*

Hour Minutes

AM/PM Option
Incident end time:*

Hour Minutes

AM/PM Option

The issue took place:*

On a single dateOver a period of timeUnknown
Please comment on unknown*
Type of incident:*

Injury: studentInjury: participantInjury: staffMissing studentMissing participantProperty damageSexual incidentVerbal outburstSwearing/ inappropriate languageMedication error/ incidentMedical/ health incidentBehavioural escalationOther
Time, if known:*

Hour Minutes

AM/PM Option
Date the issue occurred:*

MonthDayYear
Date
Start Date:*

MonthDayYear
Date
End Date:*

MonthDayYear
Date
Members of public involved?*

Yes (comment in description)No
Issue is ongoing
If anyone else was involved, please state their name(s)
Observation Length

Single observation (1 time has been observed)Multiple observations (observed more than once)Observed over a period of time
Describe the concern you observed.*
Describe why this observation is a concern.*
Was anyone alerted about this issue?

Parent/GuardianOther
Describe how and when this was reported to them:*
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?

YesNo
What has been done about this, so far?*
Any other relevant information
Was a physical injury observed?

YesNo
Were any staff members injured?

YesNo
Emergency contacts notified?*

YesNoAttempted unsuccessfully
Which room did you use?*

Calm Room - BarlowSafe Room - Barlow (When students use the safe room, please also complete the documentation form found outside the safe room.)Quiet Room - SunaltaNot ApplicableOther
Time spent in Calm Room, Safe Room or Quiet Room or Other:*
How would you describe the severity of this incident?*

MinorModerateSevereEmergency
Parents/guardians notified?*

YesNoAttempted unsuccessfully
What type of Injury?*
Describe the incident
1. Antecedents:*
What was happening immediately before the incident?
2. Incident:*
What happened?
3. Resolution: *
How did the incident conclude? What strategies were used?
4. Follow-up*
What happened after the incident?
Were emergency services required?*

YesNo
Was a PRN (pro re nata - as needed) administered*

YesNo
The student/participant's medication administration record (MAR) must be completed.
Was First Aid administered?*

YesNo
Describe what was done to treat the injury/illness:*
Allergies, if applicable:
Medications, if applicable:
Consciousness*

They were consciousThey were semi-consciousThey lost consciousness
Breathing:

They were breathing effectivelyThey were breathing ineffectivelyThey lost consciousness
Did you call for help

811/ Health linkPADISPharmacy911No
Comment on emergency services:*
Was the casualty transported to another location for treatment such as a hospital or walk-in-clinic?*

YesNo
Did you contact a parent/guardian/ emergency contact?*

YesAttempted, unsuccessfulNo
Who did you contact/attempt to contact?*
Name of First Aider

First NameLast Name
Were you the First Aider*

YesYes with someone elseNo
Name of injured student/participant 1:*
Location of injuries (student/participant 1)
Description of injuries (student/participant 1):*
Click here to add another young student/participant's injuries:
Name of injured student/participant2:
Location of injuries (student/participant 2)
Description of injuries (student/participant 2):
Click here to add another student/participant's injuries:

Add child
Name of injured student/participant 3:
Location of injuries (student/participant 3)
Description of injuries (student/participant 3):
Name of injured staff 1:
Location of injuries (staff 1)
Description of injuries (staff 1):
Click here to add another staff member's injuries:

Add staff
Name of injured staff 2:
Location of injuries (staff 2)
Description of injuries (staff 2):
Click here to add another staff member's injuries:

Add staff
Name of injured staff 3:
Location of injuries (staff 3)
Description of injuries (staff 3):
Date of submission

MonthDayYear
Date
Time of submission

Hour Minutes

AM/PM Option
Your comments: *
How could this incident be prevented in the future? What strategies were/ were not effective?
Comments of other staff members involved, if applicable:
Signature of staff member completing the form: *

Clear
Principal/Vice Principal/Program Director comments:
*FOR OFFICIAL USE ONLY*
Assistant Manager comments:
*FOR OFFICIAL USE ONLY*
Parent/Guardian Correspondence:
File Upload

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Principal or Program Director

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Incident Report

Describe the incident