Incident Report

Date*

Day of the week*

House*

Address of the Home*

Street Address Address Line 2 City

Individuals involved*

Staff at Site*

Start Time of Incident*

:

End Time of Incident*

:

Location of Incident(kitchen, bedroom, etc)*

Describe Events Prior to Incident*

Describe what was occurring prior to incident beginning. (Include description of actions and/ or verbalizations. Note any changes to routine of the day or staffing patterns):

Describe the Incident*

Describe the incident. (Describe actions and or verbalizations.)

Describe the Interventions by Staff to ensure health and welfare of the individual*

Were the interventions successful in deescalating the situation?*

Yes
No

If Yes - Put "N/A" - If No - Describe further Interventions Implemented by Staff*

What did the individual do after deescalating, did they give a reason for escalating?*

Were any client injuries noted or reported by individual?*

Yes
No

If Yes - Describe client injuries - If No - Put "No Injuries"*

Note any Medical Treatment & Follow Up

Description of Property Damage*

Did the incident involve missed or refused medications?*

Yes
No

If Yes - List the name and milligrams of all medications - If No - Put "N/A"*

Did the incident involve missed or refused physician appointment?

Yes
No

If Yes - Why was appointment missed?

Are you reporting an unknown/known injury?

Yes
No

If Yes - Describe the area, the injury and any facts related to the injury, and the care provided.

Person Notified's Title

Person Completing Form*

Person(s) Notified*

Electronic Signature Acceptance*

I Accept

By selecting the "I Accept" button, you are signing this Incident Report electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Incident Report. I also acknowledge that the events reported in this incident are truthful and accurate.

Title of Person Completing Form*

Incident Report - Connections in Ohio

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