Incident Report

Consumer:

Staff Involved:

Incident Date:

Incident Time:

Select Incident Types:

Describe Incident:

Action Taken:

Comments (optional):

Follow-Up Completed:

Name of Restrainer
(optional):

Duration of restraint
(optional):

NOTE: IF INCIDENT INVOLVES ABUSE / NEGLECT / EXPLOITATION, COMPLETE THE FOLLOWING:

Date Reported to Director: