Support Worker Incident Report Form
Use this Support Worker Incident Report Form to document and report workplace incidents involving support workers. Please provide detailed and accurate information for each section.
Date and Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Support Worker Name
*
First Name
Last Name
Support Worker Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person(s) Involved or Affected (Name and Role)
*
Type of Incident
*
Please Select
Injury
Near Miss
Property Damage
Aggressive Behavior
Other
Description of Incident
*
Immediate Actions Taken
*
Witnesses (Name and Contact, if available)
Is Follow-Up Required?
*
Yes
No
Submit Incident Report
Should be Empty: