Critical Incident Report Form
Incident Details:
*
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location (where the incident occurred within the facility)
Staff Member
First Name
Last Name
Description of Incident
Nature of Incident: (A brief description of the incident, including what happened)
Persons Involved: (Identification of individuals involved, including visitors, staff, and any witnesses)
Impact
Impact on Visitor: (Description of any harm or potential harm to the visitor)
Impact on Staff: (Description of any harm or potential harm to the staff)
Immediate Actions Taken
First Response: (Actions taken immediately after the incident)
Notification: (Who was notified and when)
Visitor Information
Visitor Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Record Number
Accounts from Staff
Names and Roles: (Identification of the staff members involved)
Accounts from Witnesses
Names and Roles: (Identification of the staff members involved)
Equipment or Resources Involved:
Identification of Equipment: (If applicable, specify any equipment or resources involved in the incident)
Critical Incident Committee Use Only Below This Line
Contributing Factors
Human Factors:
Environmental/System Factors:
Root Cause Analysis (RCA)
Investigation Details:
(Info on steps taken to investigate the root cause of the incident)
Preventive Measures:
(Recommendations for preventing similar incidents in the future)
Follow Up Actions
Corrective Actions:
(Steps take to correct immediate issues)
Preventive Actions:
(Strategies implemented to prevent similar incidents from occurring in the future)
Review and Approval
Reviewing Staff:
(Name and position of individual reviewing the incident report)
Approval:Â
(Signature or approval of the report)
Report Now!
Report Now!
Should be Empty: