Triage Form

Triage Form
This form is to be used when something occurs during a shift that requires management awareness or direction.

Please complete this form as soon as practicable when you need guidance, approval, or support (e.g. client non-engagement, early shift finish or safety concerns).

This form does not replace incident reporting.
If there is immediate risk or danger, contact 000 first, then notify Management via this form.
Date

DayMonthYear
Date
Hour MinutesAM/PM Option
Your Name

First NameLast Name
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client's Name

First NameLast Name Initial
Why do you require immediate contact?
Do you have another shift today?
Should be Empty: