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.

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* 1. Date of Incident

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* 2. Name of person filling out this form

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* 3. Individuals involved in the incident

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* 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.

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* 5. If the incident occurred in a facility (hospital, doctor’s office, etc.) was the incident reported to the facility?

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* 6. If so, provide the name of the person to whom it was reported:

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* 7. Witnesses or others present:

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* 8. Were emergency and / or safety personnel notified of the incident? 

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* 9. If so, provide the name and phone number of the person who responded to the call

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* 10. Were the family members of the person involved in the incident notified? List for each person involved in the incident. 

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