Self-Harm Incident Report Form
Please complete all fields to document the details of the self-harm incident for internal response and follow-up.
Date and time of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of incident
*
Person involved (use initials or code, not full name)
*
Type of self-harm
*
Cutting
Burning
Hitting self
Poisoning/Overdose
Scratching
Other
Method or tool used (if known)
Observed injuries
*
Minor cuts/scratches
Deep wounds
Burns
Bruising
No visible injury
Other
Immediate actions taken
*
First aid provided
Medical attention sought
Incident reported to supervisor
Family/guardian notified
No action taken
Other
Staff members involved (use initials or codes)
Brief narrative of the incident
*
Recommendations for follow-up actions
Submit Report
Should be Empty: