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Incident Report

Date of Report:*

Month

Day

Year

Time

:HoursMinutes

Caregiver Name*

Patient Name*

Incident Details

Type of Incident*

Fall

Injury

Medical Emergency

Medication Issue

Behavioral Incident

Property Damage

Missing Person

Other:

If Other, please detail type of incident

Location of Incident*

Brief Description of What Happened*

Emergency Response

Was 911 Called?*

Yes

No

Time 911 Was Called

Time

:HoursMinutes

Were Paramedics Dispatched?

Yes

No

Paramedic Assessment / Diagnosis

Action Taken by EMS

Patient treated on-site

Patient transported to hospital

Patient refused transport

Other

If Other, please detail their action

Hospital (if transported)

Notifications

Family / Responsible Party Notified?*

Yes

No

Time Notified *

Time

:HoursMinutes

Person Contacted*

ITN Management Notified? *

Yes

No

Time Notified *

Time

:HoursMinutes

Manager Contacted*

Follow-Up Actions

Immediate Actions Taken by Caregiver*

Additional Follow-Up Required*

None

Physician Follow-Up

Home Care Follow-Up

Internal Investigation

Staff Coaching

Other

If Other, please detail follow-up

Additional Comments

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