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Incident Report
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15
Questions
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1
Caregiver Name
*
This field is required.
First Name
Last Name
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2
Caregiver Email
*
This field is required.
example@example.com
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3
Client Name
*
This field is required.
First Name
Last Name
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4
Date and Time of Incident
*
This field is required.
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Date
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Day
Year
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PM
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5
Involvement
*
This field is required.
Property
Equipment
Physical
Other
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6
Complete Description of Incident
*
This field is required.
Please provide as much information as possible. What happened? Why did it happen? How did it happen? Who was involved? Were there any witnesses?
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7
Action Taken
*
This field is required.
Please describe what was done about the incident. Was first aid administered? By whom? Was a Physician notified? Was anyone taken to the hospital? If so, by whom and to which hospital?
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8
Was an Emergency Contact notified?
*
This field is required.
Yes, spoke with them.
Yes, left message.
No
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9
Who was the Emergency Contact?
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10
Was this an exposure incident?
Yes
No
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11
If yes, please describe how a wound or open sore was exposed to bodily fluid.
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12
Please list any witnesses and their contact info.
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13
Date and Time of Report
*
This field is required.
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Year
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Minutes
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14
Signature of Person Reporting
*
This field is required.
Clear
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15
[FOR OFFICE USE ONLY] Reviewed by, date reviewed, and actions to be taken to prevent reoccurrence.
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