NAME OF FACILITY:
FACILITY FILE NUMBER:
CITY:
STATE:
ZIP:

DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING
ANY INJURIES:

PERSON(S) WHO OBSERVED THE INCIDENT/INJURY:

 

EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED):

MEDICAL TREATMENT NECESSARY? YES NO IF YES, GIVE NATURE OF TREATMENT:

WHERE ADMINISTERED: ADMINISTERED BY:

FOLLOW-UP TREATMENT, IF ANY:

ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS:

LICENSEE/SUPERVISOR COMMENTS:

NAME OF ATTENDING PHYSICIAN

REPORT SUBMITTED BY / DATE:

REPORT REVIEWED/APPROVED BY / DATE:

AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)LICENSING______________________________________ ADULT/CHILD PROTECTIVE SERVICES________________________
LONG TERM CARE OMBUDSMAN___________________ PARENT/GUARDIAN/CONSERVATOR__________________________
LAW ENFORCEMENT_____________________________ PLACEMENT AGENCY______________________________________