Incident Report Form

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(240) 316-4783

GFC Services LLC

Confidential – For Internal Use Only
Submit within 24 hours of the incident or becoming aware of it.

1. Incident Details

Date of Incident: *

Time of Incident: *

Hours

Minutes

Street Address *

Apartment, suite, etc *

City *

Individuals Present: *

2. Person(s) Involved

Client Name (if applicable): *

Employee Name(s): *

Other Individuals (Name and Relationship): *

3. Incident Description

Clearly describe what happened (facts only). Include how it happened, what was observed, and any relevant context.

4. Type of Incident *(Check all that apply)Client fall or injuryMedical emergencyMedication errorEquipment malfunctionProperty damageTheft or loss of client propertyAllegation of abuse or neglectNear miss (no harm but potential existed)

Other:

5. Immediate Actions Taken *What was done at the time of the incident to address or resolve the situation?Ensured client safetyFirst aid providedEmergency services called (911)Notified supervisor or on-call specialist

Other:

Describe all actions taken: *Describe all actions taken:

6. Notifications Made *(Check all that apply)Client or client’s representative (Name):Registered NurseClient’s physicianSupervisor / On-call staffLaw enforcement (911)Adult/Child Protective ServicesOffice of Health Services (410-767-1739)

Other:

7. Follow-Up Actions and Recommendations

What follow-up actions were taken or are planned? Any steps to prevent recurrence?

8. Investigation *(for Internal Use)Investigation initiatedFindings documentedCorrective action plan developedStaff training/retraining scheduledIncident reviewed by management

9. Immediate Jeopardy?

Did the incident pose immediate danger of serious harm, injury, or death?

Yes (Notify law enforcement, Protective Services, Office of Health Services within 24 hours)No

10. Report Completed By

Name: *

Title/Position: *

Date *

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