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Client Name

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Incident Type

Injury

Medication Error

Behavioral Incident

Choking

Fall

Property Damage

Other

Severity

Low

Medium

High

Critical

Incident Title

Location

Home

School

Workplace

Community

Transport

Other

Date

Time

schedule

Injury Type if applicable

Bruise

Cut

Fracture

Sprain

Brain

Other

Required because the incident type is Injury.

Body Part Affected

Required because the incident type is Injury.

Witnesses

Immediate Actions Taken

Contributing Risk Factors

Recommended Preventive Measures

Medical Attention Required