Incident Report Form

Wellspring Main Line

Phone: (312) 648 1565

Details of person lodging this report

Please note: It is assumed that you (the person submitting this form) are the health care worker who was present at the time of the incident.

Your First Name

Your Last Name

Your email address

Your phone number (optional)

Client / Patient Details

First Name

Last Name

Is the individual a current patient?

Specifics of the Incident

Short Succinct Summary of the incident (akin to an email subject)

Date of Incident

Approx. Time of Incident

Where did the incident occur?

Other info

What were you doing at the time of the incident?

What was the client doing at the time of the incident?

Nature of injury to client

Nature of injury to yourself

Describe any unsafe condition or act that caused or contributed to the incident