Employee Non-Critical (ENC)

Employee Non-Critical (ENC)
First Name:
Last Name:
Phone Number:
Employee Email:
Location:
Team Leader's Email:
Team Leader
Start Time:

Hour Minutes

AM/PM Option
End Time:

Hour Minutes

AM/PM Option
I am a:
Classification:
If a client was involved, put their initials here:
Date and Time of Incident:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Date of Report

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Injury
(ie. fall, allergy, struck, sprain, psychological, etc.)
How many days worked this week:
How many hours worked today
IF YOU CALL AN AMBULANCE AND/OR GO TO THE HOSPITAL, CALL
KIM 604-785-9032 or MELANIE 604-809-5996 IMMEDIATELY

Please call Staffing or Kim if you see a medical provider or require time off
If the incident was due to client movement or behaviour, use the rating scale below to indicate how hard it was. Please use the slider to view all options.
If the incident was due to muscle strain, use the rating scale below to indicate how hard it was. Please use the slider to view all options.
Full Description of Incident:
Indicate the location of the injured body part(s). Circle with a pen or use the shapes.
Indicate the location of the injured body part(s). Circle with a pen or use the shapes.
Should be Empty: