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Incident Report
Confidential Incident Report
If you are involved in an incident involving an injury or property damage, please call your Hearts and Hands coordinator who will complete this form.
1.
Date of Incident
2.
Name of person filling out this form
3.
Individuals involved in the incident
Name:
Age:
Address:
Phone:
Role at Hearts & Hands:
Name:
Age:
Address:
Phone:
Role at Hearts & Hands:
Name:
Age:
Address:
Phone
Role at Hearts & Hands:
4.
Description of the incident- Include who was involved, the date, time and location of the incident, how the incident occurred, list any witnesses, and any injuries or property damage that were incurred.
5.
If the incident occurred in a facility (hospital, doctor’s office, etc.) was the incident reported to the facility?
Yes
No
6.
If so, provide the name of the person to whom it was reported:
7.
Witnesses or others present:
Name:
Address:
Phone:
Notes:
Name:
Address:
Phone:
Notes:
Name:
Address:
Phone:
Notes:
8.
Were emergency and / or safety personnel notified of the incident?
Yes
No
9.
If so, provide the name and phone number of the person who responded to the call
10.
Were the family members of the person involved in the incident notified? List for each person involved in the incident.
