Employee Incident Report v4 (1)

Employee Incident Report

Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com, 28000 Woodward Ave., Royal Oak, MI 48067

Employee Division: *

Private Duty Nursing/Home and Community Services

Behavioral Services

Employee Information

First Name: *

Last Name: *

Title: *

Age: *

Location of Incident: *

Date of Incident: * +

Time of Incident (in military time): *

Property involved? *

Yes

No

Equipment contributed to incident? *

Yes

No

Describe property or equipment involved? *

Type of Incident: *

Description of incident by person involved (what happened, why it happened, what the causes were, etc. If an injury, state part of body injured. If property damaged, describe damage.): *

If the incident was a bite, does the child that did the biting have a Behavior Intervention Plan (BIP)? *

Yes

No

Name of client who bit employee:

If ICE Raid or Law Enforcement other than ICE Raid, please provide information regarding the agents / officers and the nature of the interaction: *

Witness/Client Information:

Was there a witness/client present when the incident occurred? *

Yes

No

(If you were on shift but not with the client at the time the incident occurred, please put the name of the client whose case you were working on at the time the incident took place)

Witness/Client First Name:

Witness/Client Last Name:

Street Address:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

Was it necessary to contact a physician? *

Yes

No

Time of Notification:

Time Responded:

Was the person involved seen by a physician? *

Yes

No

Physician's name or name of hospital/Emergency Department:

Was a HealthCall supervisor notified? *

Yes

No

Name of Supervisor Notified:

Time:

Instructions from Supervisor:

First Name of person filling out report: *

Last name of person filling out report: *

Title of person filling out report: *

Date of Report: * +

v4 - 10.01.23