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.
Client's Name *

First NameLast Name Initial
Why do you require immediate contact?

Client : Non-Engagement/ refusal of servicesClient : Wants to end shift earlyStaff : Late to shiftStaff : Availability Issue - Unavailable to make my shift(s)Client : Medical EmergencyEnvironmental risk (property damage, hazards, community incident)
Do you have another shift today?

YesNo
Should be Empty: