2. Instructions
• All incidents should be reported within 24 hours unless the incident leads
to direct harm of the employee or patient which may require immediate
attention
• Employee’s direct supervisor should be notified of all incidents
• There are four parts to the incident report:
(all parts should be filled out as completely as possible)
Part 1 -Consumer, Incident, & Witness General Information
Part 2- Incident Details
Part 3- Type of Occurrence
Part 4- Signature
3. Part 1
PART 1: Consumer, Incident & Witness General Information
Consumer name: _______________________________________________________________
Address: ______________________________________________________________________
City: ________________________ State: _____ Zip: __________
Phone: _______________________________
Location of incident: ____________________________________________________________
Date of incident: ______________ Time incident occurred/ discovered: ___________
Witness name/phone: ____________________________________________________________
Witness name/phone: ____________________________________________________________
Consumer condition prior to occurrence: (select all that apply)
☐Alert/ oriented ☐Disoriented/confused ☐Sedated/medicated
☐Weak/dizzy ☐Combative/assaultive ☐Senile dementia/Alzheimer’s
☐Unconscious ☐Visually impaired ☐Hearing impaired
☐Walked w/device ☐Walked independently ☐Walked w/person(s)
☐Bed only ☐Chair only
☐Other (describe):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. Part 2
PART 2: Incident Details
Severity of incident -Provide a brief narrative description of incident (factual information only):
☐No apparent injury ☐Minor (first aid) ☐Moderate (fracture, sutures)
☐Severe (hospitalization ☐Death
Description of injury (if any): ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Response to incident (select all that apply):
☐First aid ☐Consumer refused treatment ☐Called 911
☐Admitted to hospital ☐No intervention ☐Unknown
Provide further description, if necessary, of the actions you took in response to this incident:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Individuals Notified (select all that apply):
Supervisor/ manager
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________
Physician
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________
Family
Name of individual notified: _____________________________________________________
Date/ time of notification: _______________________________________________________
5. Part 3
PART 3: Type of Occurrence (select all that apply)
Fall Occurrence: ☐Observed ☐Not Observed
☐Found on floor ☐From toilet ☐While ambulating
☐During transfer ☐Out of bed ☐Eased to floor
☐Out of chair ☐Slip/trip ☐Out of wheelchair
☐Other (describe): __________________________________________________
Miscellaneous Occurrence: ☐Observed ☐Not Observed
☐Fire ☐Consumer refuses treatment
☐Burn ☐Unplanned absence of caregiver
☐Abuse ☐Caregiver and/or consumer issues
☐Complaints of theft ☐Home care staff & consumer disagreement
☐Damage to personal property ☐Safety issues
☐Other (describe): __________________________________________________
Equipment Occurrence: ☐Observed ☐Not Observed
Related to: ☐Fire ☐Consumer refuses treatment
☐Equipment malfunction ☐Catheter ☐Life-sustaining equipment
☐Implanted device ☐Infusion pump ☐Disposable device
☐IV ☐Other (describe): _____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PART 3: Continued
Medical Occurrence: ☐Observed ☐Not Observed
☐Consumer error ☐Caregiver error ☐Employee error ☐Pharmacy error
Type of medication intake: ☐Oral ☐IM ☐IV
☐Other: _____________________________________________
Type of medication incident: ☐Adverse allergic reaction ☐Wrong medication
☐Extra dose ☐Wrong time ☐Wrong dose ☐Wrong routine
☐Missed dose ☐Late delivery ☐Mislabeled
☐Other (describe): _______________________________________________________________
6. Part 4
• Part 4: Signature of Person Completing this Form
• Signature: ___________________________________________
• Print name: __________________________________________
• Date: _____________________
7. Incident Report Log
Date Time Reported Person Reporting Type of Occurrence Supervisor Notified Report Completed
Incidents will be recorded in logbook by month/year
If no occurrences, it shall be noted by a diagonal line across the page and signed by appropriate authority
