Client Incident Report

CAREGiver Full Name

Occurrence Date:

Occurrence Time

Client Full Name:

Client Sex:

Address:

Phone:

Location of Incident

Witnesses Present

Name & Phone Numbers of Witness

Date of Report

Check Applicable Event:

Describe the event (Only report facts- Who, What, When, Where):

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IF INJURY OCCURRED

First Aid Administered?

What Kind of First Aid Administered:

Who Administered the First Aid (Name & Phone #)

Physician Notified?

Name of Physician Notified:

Taken to Hospital?

Who Took the Patience to the Hospital?

Hospital Name

Was Emergency Contact Notified?

Name and Relation of Contact Notified:

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