About You Incident Report

(Please check if applicable)

Client*

Date*

Time*

Type of Incident, Accident, Abuse, or Neglect (Check all which apply):

Exact Location of Incident/Accident, Abuse/Neglect:

Who was contacted?

Name of person notified*

Date*

Time*

If Doctor was notified, was an order obtained or instruction provided?*

Describe what may caused or led up to the Incident/Accident or Abuse/Neglect*

Describe exactly what happened at the time of the Incident/Accident or Abused/Neglect*

Action taken by staff at time of Incident/Accident or Abuse/Neglect.*

Education provided on how to prevent further incidents/accidents?*

Client/Guardian Name*

Client/Guardian Signature

Date

Worker Name*

Worker Signature

Date

Supervisor Name*

Supervisor Signature

Date