Incident Report

A serious incident is any event or circumstance that jeopardizes the health, safety or well-being of the client, family member or employee of Next Gen Therapy LLC. Examples of a serious incident include, but are not limited to, abuse or neglect; criminal behavior; death, emergency medical treatment; facility-related issues, such as fires, flood or destruction of property; food-borne diseases; serious infractions of facility or school rules; physical assault or other dangerous acts of aggression; sexual misconduct or assault; use of illicit or dangerous substances; serious illness (such as tuberculosis, meningitis or other communicable diseases); physical injury (accidental or otherwise); medication errors or client refusal of medication; attempted suicide; and unexplained absence.
First Name*
Last Name*
Title*
Date of the incident*
Month
Day
Year
Time of the incident*
Client's First Name*
Client's Last Name*
Witness Information*
Location of the incident*
Who was injured? (Check all that apply)*
- Select All
- Injury to staff
- Injury to client
- Injury to other
Who was injured?*
Enter the ages and genders of each person injured*
Briefly describe the incident*

Safety Care Information

No items found.