* Indicates required questions
Please do not include any client name information. Use initials only.
Email *
Employee/Staff Name: *
Gender *
Female
Male
Job Classification *
Did this Accident/Incident involve a client?  *
If Yes, please provide client INITIALS only.
Accident/Incident Date (Mo/Da/Year) *
Accident/Incident time? Please specify AM or PM.  *
Accident/Incident Geographic Location (Address, City, Client Home, Etc.) *
Describe how the accident/incident occured, include what activity was happening immediately before the accident/incident. ONLY USE CLIENT INITIALS IF NECESSARY *
Immediately following the accident/incident, you must contact the On-Call Coordinator or the Office. please indicate who was notified: *
Name of object or substance that may have attributed to the accident/incident: *
Body part(s) affected (check all that apply): *
Eye
Hand
Hip
Respiratory
Neck
Back
Knee
Heart
Shoulder
Chest
Leg
Arm
Abdomen
Ankle
Foot
Fingers
Other - Please specify:
If other, please specify:
Activity (check all that apply): *
Falling/Tripping: Wet surface
Falling/Tripping: Snow/Ice
Falling/Tripping: Obstacle
Falling/Tripping: Another person
Contact/Exposure With: Needle
Contact/Exposure With: Scalpel
Contact/Exposure With: Glass
Contact/Exposure With: Equiptment
Contact/Exposure With: Electricity
Contact/Exposure With: Natural Gas
Contact/Exposure With: Body Fluids
Contact/Exposure With: Chemical
Other: Motor Vehicle Accident
Other: Pulling/Pushing
Other: Lifting
Other: Transferring
Other - Please specify:
If other, please specify:
Potential cause (check all that apply): *
Failure to use gait belt
Unsafe action
Unsafe condition
Unsafe equiptment
Safety device failure
Safety device not used
Combative client
Violation of safety policy
Excessive weight
Other - Please specify:
If other, please specify:
Location (check all that apply): *
Parking lot/side walk
Kitchen
Hallway
Laundry
Bedroom
Bathroom
Activity/Common Room
Shower/Bathroom
Office
Dining Room
Other - Please specify:
If other, please specify:
Employee Signature - Please Type *

Accident/Incident Report

Please complete the form to the left to submit your Accident/Incident Report electronically.