Incident Report Form Template for documenting incidents involving clients, caregivers, or staff. This template will help agencies maintain detailed and consistent incident documentation, assisting in both compliance and quality assurance efforts.
Incident Report Form
Instructions: Complete this form as soon as possible following an incident. All sections must be filled out accurately and in full. Attach any additional documentation if needed.
Section 1: Basic Information
Date of Report: ____________________
Time of Report: ____________________
Section 2: Reporter’s Information
Name of Person Reporting Incident: ____________________
Role/Position: _______________________________________
Contact Information:
Phone Number: __________________________________
Email: __________________________________________
Section 3: Incident Details
Date of Incident: ____________________
Time of Incident: ____________________
Location of Incident: ________________________________
Specific Area/Room (if applicable): ____________________
Section 4: People Involved
1. Name: ______________________________________________
Role (e.g., Client, Staff, Visitor): _______________________
Contact Information (Phone/Email): ____________________
2. Name: _______________________________________________
Role: ______________________________________________
Contact Information: _________________________________
(Add additional sections if more individuals were involved)
Section 5: Description of Incident
Provide a detailed account of the incident, including what happened, how it occurred, and any contributing factors.
Incident Description:_________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Was the incident witnessed by anyone?
If yes, name of the witness(es): ____________________
Section 6: Immediate Actions Taken
Detail any actions taken immediately following the incident (e.g., first aid, emergency services contacted, staff intervention).
Action(s) Taken:
Was 911 or emergency services contacted?
If yes, provide details: _______________________________________________________________
Section 7: Follow-Up Actions Required
List any further actions required following the incident, such as medical evaluation, behavioral assessment, client reassessment, or facility repairs.
Follow-Up Actions Needed:
Expected Completion Date: ____________________
Section 8: Reported To
Indicate whom this report has been submitted to within the agency.
Name: ____________________
Position/Title: ____________________
Date Reported: ____________________
Section 9: Signature and Acknowledgment
I confirm that the above information is accurate to the best of my knowledge.
Reporter’s Signature: ____________________
Date: ____________________
Supervisor’s Signature (if applicable): ____________________
Date: ____________________
Note
For a customized incident report form tailored to your state’s specific regulations, please reach out to us for assistance. Call 302.888.9172 or email us at licensing@waivergroup.com.
Additionally, visit our Policy and Procedure page for a full range of documents designed to support agencies like yours. Our Waiver Consulting Group can provide the expertise and resources to help you streamline operations and maintain compliance.