Client Incident Report

Client(s) M.R. #:                                                       Date:

Staff on Duty:

Was staff involved in the incident?

Did staff witness incident:

Incident Type: (check one)

	Abuse/Neglect/Exploitation		Automobile Accident		Sexual Battery
	Use of Alcohol		Baker Act		Suicide Attempt
	Aggressive/Abusive Behavior		Client Death		Theft
	Use of Drugs		Elopement		Verbal threat of violence
	Altercation		Law Violation		Other (explain on page 2)

Describe Incident In Detail on Page 2 of This Report:

Action Taken:

Supervisor Contacted:                                     Name of Supervisor:

Called 911                                                   Follow up Necessary:

Describe Incident:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisory Intervention Strategy:

Describe Intervention:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisor Signature: ___________________________   Date:__________________________________

Printed Name:________________________________

Executive Director Comments:

Comments: __________________________________________________________________________________________________________________________________________________________________________________

Executive / Clinical Director Signature: ________________________________________________________

 

Describe Incident:

 

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