Subject: Risk Prevention and Management

COA: PQI 4.02, RPM 2, RPM 2.01, RPM 2.02, RPM 2.03 Applies to: Entire Organization

Employee/Volunteer Incident/Accident Report

Form Number: 1027-29 Effective: June 27, 2007 Revision effective: July 28, 2010 Reviewed:

Date of Incident/Accident: Individual Involved: Individuals Home Address: Witnesses: Facility Location:

Time of Incident Employee

AM Volunteer

PM Visitor

Individuals phone number: Department/Program:

I.

Type of Incident: (Place an X next to the occurrence(s) being reported) Employee Injury* Volunteer Injury APS/CPS Report** Police Report*/** Other: Vehicle Accident* Substance Usage Stealing Facility Safety Issues Allegation of Abuse/Neglect*/** Verbal Abuse/Threat Physical Aggression/Violence Property Damage/Vandalism

* Attach Appropriate Forms (i.e. Police Report, Physician Report) ** Include Reference Number provided by Statewide Intake or Police in Section III of this report.

II.

Description of incident/accident: (Site detailed information of the occurrence)

III.

Action(s) taken and results of this incident/accident: (i.e. consequences and follow-up efforts)

V.

Risk prevention and Management: Yes No (law enforcement/CPS/APS)* Date: Time AM PM

A. Authorities Notified? If Yes, Who: 1.

2. 3. B. Parent/Legal Guardian Notified? If Yes, Who: 1. 2. C. Human Resource Notified? If Yes, Who: 1. 2. D. Business Manager Notified? If Yes, Who: 1. 2. Yes Yes No

Date: Date:

Time Time

AM AM

PM PM

Date: Date: No Date: Date:

Time Time

AM AM

PM PM

Time Time

AM AM

PM PM

Yes

No Date: Date: Time Time AM AM PM PM

E. Additional Comments: _ _ ___________________________________________________________________________________________

Employee preparing report (include credentials and position title)

Date

F. Employee Signatures Supervisor/Coordinator Director Vice President of Quality Assurance

Initial

Date

G. Follow-up Action needed (To be completed by Human Resource/Business Manager, as applicable): _ _ ___________________________________________________________________________________________ Days Away From Work: Date return to work: Days restricted to light duty: Date return to full duty: