Incident Report Form
Please fill out form completely. An incident is any happening which is not consistent with the routine care of a particular patient, or a situation that may result in an accident.
Person Involved Full Name
*
First Name
Last Name
Date of Incident/Accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident/Accident
*
Hour Minutes
AM
PM
AM/PM Option
Person Type
*
Employee
Patient
Visitor
Other
Age Group
*
Adult
Child
Other
Exact Location of Incident/Accident
*
Patient's home
Facility
Other
Address/Location
Patient Condition Before Incident
*
Normal
Confused
Disoriented
Sedated
Agitated
N/A
Other
Type of Incident
*
Procedure Error
Medication Error
Fall
Loss
Breakage/Damage
N/A
Other
Employee Full Name
*
First Name
Last Name
Employee Job Title
*
Incident Description
Description of Incident by Person Involved
Describe exactly what happened, why it happened, and what causes were identified.
*
Part of Body Injured
Property or Equipment Damaged Description
Witness Name, Address and Phone Number
Medical Notification and Follow-up
Was it Necessary to Notify MD?
*
Please Select
Yes
No
Time of notification
Hour Minutes
AM
PM
AM/PM Option
Time Responded
Hour Minutes
AM
PM
AM/PM Option
Was Person Seen by a Physician or Emergency Room?
*
Please Select
Yes
No
Time Seen:
Hour Minutes
AM
PM
AM/PM Option
Physician Name or Hospital
Was First Aid Administered?
*
Please Select
Yes
No
First Aid Administered By Whom
Type of Injury
*
Laceration
Hematoma
Abrasion
Burn
Swelling
Fracture
None Apparent
Other
Notifications made:
*
Family
Conservator
Case Manager
Other
Additional Comment and/or Steps Taken to Prevent Recurrence
*
Report Completion
Person Preparing Report
*
First Name
Last Name
Report Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: