Incident Report Form

Incident Report Form

Instructions: Complete this form as soon as possible after the incident occurs. Provide clear, factual, and objective information. Avoid assumptions or opinions.

Attach supporting documentation if applicable:

Photos Witness Statements Medical Reports Security Footage Emails/Logs
Section 1: Report Information
Date of Report:
Time of Report:
Report ID / Reference Number:
Section 2: Person Completing Report
Full Name:
Job Title / Role:
Department / Unit:
Phone Number:
Email Address:
Section 3: Incident Details
Date of Incident:
Time of Incident:
Location of Incident
  • Office / Workplace
  • Client / Customer Location
  • Facility / Site
  • Public / Community Area
  • Remote / Virtual Environment
  • Other:
Specific Area (if applicable):
Section 4: Individuals Involved
Individual #1
Name:
Role: Employee Client Customer Visitor Contractor Other:
Contact Information:
Individual #2
Name:
Role: Employee Client Customer Visitor Contractor Other:
Contact Information:

(Attach additional pages if needed)

Section 5: Witness Information
Were there witnesses? Yes No
Witness #1
Name:
Contact Information:
Witness #2
Name:
Contact Information:
Section 6: Incident Classification

(Check all that apply)

  • Injury / Illness
  • Fall / Slip / Trip
  • Property Damage
  • Equipment Failure
  • Behavioral Incident
  • Safety Hazard
  • Security Breach / Theft
  • Medication / Service Error
  • Complaint / Grievance
  • Near Miss (no injury but potential risk)
  • Other:
Section 7: Detailed Description of Incident

Provide a clear, factual account:

Section 8: Immediate Actions Taken

Describe actions taken:

Were emergency services contacted? Yes No
If yes, provide details:
Section 9: Injury / Damage Details
Injury Information
  • No Injury
  • Minor Injury
  • Serious Injury
  • Fatality
Description of injury:
Was medical treatment required? Yes No
Location of treatment:
Property / Equipment Damage
  • None
  • Minor Damage
  • Major Damage
Description of damage:
Section 10: Root Cause & Contributing Factors (Internal Use)
  • Human Error
  • Equipment Failure
  • Environmental Hazard
  • Policy/Procedure Gap
  • Training Issue
  • Communication Breakdown
  • Other:
Section 11: Corrective & Preventive Actions
Actions Required:
Responsible Person:
Target Completion Date:
Section 12: Notifications
Supervisor / Manager Name:
Position / Title:
Date Notified:
Additional Notifications:
  • Senior Management
  • Client / Customer Representative
  • HR Department
  • Compliance / Risk Department
  • Insurance Provider
  • Regulatory Authority
  • Law Enforcement
  • Other:
Section 13: Attachments
  • Photos
  • Witness Statements
  • Medical Reports
  • Security Reports
  • Other:
Section 14: Signatures
Reporter
Name:
Signature:
Date:
Supervisor / Manager Review
Name:
Signature:
Date:

Compliance Note: This form is intended to assist agencies in documenting incidents in accordance with home care regulatory requirements, Medicaid waiver programs, and agency risk-management policies. Agencies must follow all applicable state-specific reporting requirements and timelines.