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Incident Report Page 1

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If this is a true emergency call 911 immediately!

A serious incident is any event or circumstance that jeopardizes the health, safety or well-being of the client, family member or employee of {Company Name}. Examples of a serious incident include, but are not limited to, abuse or neglect; criminal behavior; death, emergency medical treatment; facility-related issues, such as fires, flood or destruction of property; food-borne diseases; serious infractions of facility or school rules; physical assault or other dangerous acts of aggression; sexual misconduct or assault; use of illicit or dangerous substances; serious illness (such as tuberculosis, meningitis or other communicable diseases); physical injury (accidental or otherwise); medication errors or client refusal of medication; attempted suicide; and unexplained absence.

*First Name:

*Last Name:

*Title:

*Date of Incident:

*Time of Incident:

*Client's First Name:

*Client's Last Name:

*Witness Information:

*Location Of Incident:

*Who Are Injured? (Check All That Apply)
Injury To Staff
Injury To Client
Injury To Other
No Injury

*Who Was Injured?

*Enter the ages and genders of each person injured:

*Briefly describe the incident:

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Incident Report Page 3

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Post Incident Details

*Who was notified of the incident and when?

*Recommendations to avoid the situation in the future:

ABC Data

List all ABC data below, number each one so it is easy to know the order.

*Antecedent (list each one using numbers):

*Behavior (list each one using numbers):

*Consequence (list each one using numbers):

Signature:

Clear

Please sign here

*Date Completed :

Elbow Check	Protective Stance
Supportive Guide	Shoulder Check
Safety Shuffle	Stripping a Grab
Wrist Release	Choke Release
Hair Pull Release	1-Person Stability Hold
Bite Release	Forward Escort
2-Person Stability Hold	Seat Stability Hold
Reverse Escort	Leg Wrap
Chair Stability Hold	Not Applicable
Safety Stance

Incident Report Page 1

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Incident Report Page 2

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Incident Report Page 3

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