OmaCare Home Care Service
Incident Report Form
Incident Report Form
EMPLOYEE INFORMATION
Employee Name:
Job Title:
Date of Incident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Location of Incident:
Client Name (if applicable):
TYPE OF INCIDENT
TYPE OF INCIDENT
Client Injury
Employee Injury
Fall
Medication Error
Behavioral Incident
Property Damage
Abuse/Neglect Allegation
Safety Hazard
Infection Exposure
Other
DESCRIPTION OF INCIDENT
Please provide a detailed description of what occurred, including events leading up to the incident.
ACTIONS TAKEN
Back
Next
Emergency Services Contacted
Supervisor Notified
Family/Responsible Party Notified
First Aid Provided
Client Assessed
Employee Sent for Medical Evaluation
Incident Scene Secured
Additional Details:
WITNESS INFORMATION
Witness #1 Name:
Phone Number:
Statement:
Witness #2 Name:
Phone Number:
Statement:
INJURY INFORMATION
Was anyone injured?
Yes
No
Describe injuries:
Was medical treatment required?
Yes
No
Where was treatment received?
FOLLOW-UP / CORRECTIVE ACTION
Describe steps being taken to prevent recurrence of this incident.
Back
Next
REPORTING INFORMATION
Date Report Completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Signature:
Supervisor Signature:
Date Reviewed by Supervisor:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
CONFIDENTIALITY NOTICE
This incident report contains confidential information intended solely for internal use by OmaCare Home Care Service management and authorized personnel. All incidents must be reported promptly in accordance with company policy and applicable state and federal regulations.
Preview PDF
Submit
Should be Empty: