Documenting Appendix 4
Approved January 2009
NON-CLIENT RELATED INCIDENT REPORT

Date of Incident:
Time of Incident:
Location of Incident:
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 the 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 the incident occur?  What factors may have contributed to the incident?)

Details of Staff Debriefing:

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

Follow-up Required/Action Plan

Who was Notified and When: