INCIDENT REPORT FORM Senior Home Support & Home Health Support A. About you (person reporting incident) Name:  _________________________________  Job Title:_______________________ B. About the person affected by the incident (status):   Employee      Senior    Student   Other:  _________________________________________________________________ Name of person affected: ___________________________________________________ C.  About the incident: Date of Incident:___________  Time of incident:  __________ Date of report:_________ Location of incident (where did it happen): ________________________________________________________________________ Describe what happened:  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ D. Staff Involved/Witnesses:  Were there any?    No       Yes    If yes, please list Name:  ________________________  Location at time of incident:  _______________  Name:  ________________________  Location at time of incident:  _______________  Name:  ________________________  Location at time of incident:  _______________  Are there any witness statements attached:    No     Yes Internal/External persons contacted: _______________________________________________________________________ E. About the injury and any treatments given: What was the injury? _______________________________________________________________________ What part of the body was injured?  _______________________________________________________________________ Who administered the treatment?: Client Doctor  Personal Doctor   Emergency Room   Self Administered  Occupational Health  Other: _________________________________________________________________ Description of treatment: ___________________________________________________ Signature/Date:  __________________________________________________________ (See back)

TO BE COMPLETED BY SUPERVISOR F.  Supervisor Response:  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ G.  Employee time lost: Injured party completed shift:    Yes     No Absence commenced (date): _____________ Absence ended (date): _________________ Length of absence (days):_______________ Supervisor Signature/Date: ________________________________________________________________________ CRITICAL INCIDENT REVIEW TEAM Actual outcome of the incident:  Insignificant   Minor   Moderate  Major  Catastrophic Likelihood of recurrence:  Rare   Unlikely Possible     Likely     Almost certain Recommended actions:     None needed Notification: (Indicate any persons who should be notified both internally and externally): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Investigation: (Indicate who will investigate what.  Indicate who will receive the report) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Training: (Indicate additional training required) _________________________________________________________________________ _________________________________________________________________________ Other: (Indicate other actions recommended) _________________________________________________________________________ _________________________________________________________________________ Review Team Signatures/Date _________________________________________________________________________ _________________________________________________________________________