Documenting – Appendix 3 – Client Incident Report
Approved January 2009
CLIENT INCIDENT REPORT

Client Name:
File Number:
FPS# (Buffalo Street Residence)
Date of Birth:
Date of Incident:
Time of Incident:
Location of Incident:
Serious Occurrence # (if applicable):
Type of Incident (i.e. Incident Report Category):
Date Incident Report Written:
Time Incident Report Written:
Name of Staff Making Report:
Name(s) of Staff on Shift or in the Facility at the Time of Incident:

Details/Description of the Incident (Please describe the Who, What, Where, When and Why i.e. Who was involved?  What happened?  When did it happen?  Where did it happen? What factors contributed to the incident i.e. substance use?)

Details of Client Debriefing:

Client Debriefing Conducted by: (Name of staff and date)

Details of Staff Debriefing:

Staff Debriefing Conducted by: (Name of staff and date)

Follow-up Required/Action Plan

Who Was Notified and When:

Service Director                                                                                             Date
Manager                                                                                                         Date
Supervisor (if applicable)                                                                             Date
CAS Worker (if applicable)                                                                         Date
Client’s Parent/Guardian/Caregiver (if applicable)                                   Date
Probation/Parole Officer                                                                              Date
Police Officer (Name, Badge and Report Number, if applicable)            Date
Other (Who)                                                                                                  Date