Incident Report

Incident
Date Reported

MonthDayYear
Date
Time
Reported
3 Location of Incident
4. Individuals Involved in Incident & Status (i.e. Employee/Client/Family/Other--Specify):

5. Incident Witness & Status (i.e. Employee/Client/Family/Other--Specify)
6 Witnesss Description of Incident
Incident Resulted in Injury (Tick One):
If Yes Describe Injury
7. Incident Reported by (Identify Name & Status; i.e.: Employee/Client/Family/Other--Specify
Name
Status
Phone No
Format: (000) 000-0000.
Signature
Name
Title
Phone
Format: (000) 000-0000.
9 SupervisorsInvestigators CommentsFindings
10. Was Incident Preventable? (Tick One):
11 Suggested Corrective Actions
12. Hotline/Other Authority Notified (Tick One):
of
Other
Authority
13. Person Who Notified Hotline/Other Authority:
Date

MonthDayYear
Date
Name
Title
SupervisorsInvestigators Signature
14 Agency Manager ReviewCommentsActions
Agency Managers Signature
Date

MonthDayYear
Date
Should be Empty: