Incident Report Form
This form is to be completed by the Owner/Operator or designated Program Director immediately following any sentinel event. Fatalities must be reported within 24 hours. All other incidents must be reported within 72 hours.
Recovery Residence Name
Owner/Operator or Program Director Completing This Form
Date GARR Was Notified (if already notified personally)
-
Month
-
Day
Year
Date
Date of Incident
-
Month
-
Day
Year
Date
Location of Incident
Type of Incident
Resident Fatality (24-hour reporting)
Non-fatal Overdose
Serious Injury Requiring Hospitalization
Medical Emergency
Missing Resident / Elopement
Violence or Assault
Arrest or Criminal Activity on Property
Fire or Environmental Hazard
Other
Was Emergency Medical Services (EMS) contacted?
Yes
No
Detailed Description of the Incident
(Include events leading up to the incident, who discovered it, timeline, and actions taken.)
Immediate Actions Taken by Staff
Current Status of the Resident(s)
Examples: transported to hospital, returned to residence, missing, deceased, etc.
Safety Measures Implemented After the Incident
Supporting Documentation Upload
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(EMS records, police reports, internal logs, photos, etc.)
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of
Attestation
I attest that the information provided in this report is complete and accurate to the best of my knowledge. I understand that all fatalities must be reported to GARR within 24 hours, and all other sentinel events within 72 hours.
Electronic Signature
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