Incident Report
Date of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Emergency Code
Blue - Cardiac
Red - Fire
Cyndi in Labour - Violence/Aggression
Yellow - Missing Person
Black - Bomb Threat
Green - Evacuation
Grey - Air Exclusion
Brown - Hazardous Spill
Orange - Disaster/MCI
List of Clients Involved:
List of Staff Involved:
Email of Person Completing Report
*
example@example.com
Supervisor's Email
*
example@example.com
*
Rows
No
Yes
Was anyone injured?
Was medical attention sought?
Was this a suspected OD?
Reported to the police?
Description of Incident
*
Requesting Review
*
Yes
No
If requesting review, please note your recommendation action for Management Team consideration?
*
1 week BIS
2 week BIS
3 week BIS
30 day BIS
Other actions and/or follow up recommended
Submit
Should be Empty: