Scribd
Upload
29 views2 pages

Incident Report Template

The document is an Incident/Accident Report form used to record details of an incident occurring at a facility, including the date, time, location, type of incident, and the condition of the resident involved. It also captures information about any equipment or property involved, injuries sustained, and notifications made to medical personnel and family members. The form requires signatures from staff and witnesses to validate the report.

Uploaded by

melissaherriges
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
29 views2 pages

Incident Report Template

The document is an Incident/Accident Report form used to record details of an incident occurring at a facility, including the date, time, location, type of incident, and the condition of the resident involved. It also captures information about any equipment or property involved, injuries sustained, and notifications made to medical personnel and family members. The form requires signatures from staff and witnesses to validate the report.

Uploaded by

melissaherriges
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Incident/Accident Report

Date of Incident: Time of Incident: Location of Incident:  Dinning Area  Bedroom  Bathroom  Hallway  Away from Facility
AM
: PM
 Other (Specify):
Type of Incident:  Fall  Argument  Physical Altercation/Fight/Assault  Theft  Threat  Endangerment  Neglect
 Other (Specify):
Residents condition before Incident/Accident:  Normal Confused Disoriented AM
 Sedated (Medication: Dose: ) *Time of most recent dose of regular meds : PM
Were Bed Rails present? If Yes, were bed rails: Was bed height adjustable? If, yes was bed:
 Resident
 Yes No  Yes No  Yes No  Yes No
Was a restraint in use at time of the incident?  Yes No Emotional Status:
Specify Restraint Type:
Job Title: Length of time in position: Emotional Status:
 Employee
Name: Phone: Email:

 Witness Address: Emotional Status:

 Visitor Name: Phone: Email:


* Was person
authorized to be at Address: Reason for presence at Facility: Emotional Status:
location during time
of the incident?

 Equipment Involved Describe:___________________________________________________________ * Was person authorized to use


equipment or handle property?
 Property Involved Describe:  Yes No
Show locations of injuries on diagram below

Temp:____________ Pulse:__________ B/P:_____________

Type of Injury

1. None Apparent 
2. Abrasion 
3. Skin Tear 
4. Laceration 
5. Hematoma 
6. Swelling 
7. Burn 
8. Sprain 
9. Fracture 
10. Other (Specify Below) 
___________________

LEVEL OF CONSCIOUSNESS:
 Normal  In & Out  Unconscious

Name of Physician Notified: Time of Notification: AM Time Responded: AM


: PM : PM

Name of Family Member/Resident Representative Notified: Time of Notification: AM Time Responded: AM
: PM : PM

Name of Family Member/Resident Representative Notified: Time of Notification: AM Time Responded: AM
R : PM : PM

Was First Aid Required? Yes No By Whom? Where Date: Time:


AM
What Type: CPR AED Bleeding
PM
Broken Bone Burn Choking

Was person involved transported via If no, why not? To Where: Time: AM
EMS? Yes No PM
Incident/Accident Report
Describe Incident Below:

STAFF SIGNATURE/TITLE/DATE WITNESS SIGNATURE/TITLE/DATE

You might also like