Capital Mental Health Association – Incident Reporting Form

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Date:This is the date of the event. In the event of a disclosure or allegation, you would use the date the disclosure/allegation was made. If you were not present for an incident, this is the time you became aware of the incident. / Location of Incident
This is the location of the event. This will usually be a CMHA worksite, but it may be in the community. / Name of Staff Completing Report
Your Name, only. If several staff were involved in an incident, each must complete an incident report separately.
Time:Time the incident occurred or began, or the time you became aware of the incident.
Nature of Incident: Subject of Incident/Accident Client Staff
Allegation of (any of the below)
Medication Error:(type)
Use of seclusion or restraint
Violence/aggression towards staff
Violence/aggression towards client
Abuse or neglect
Staff Conflict
Sexual Assault / Suicidal ideation
Suicide or attempted suicide
Elopement/Wandering
Biohazard Event
Intoxication
Communicable Disease
Infection Control
Client/Community Complaint / Possession of weapon
Possession of drugs/Alcohol
Vehicular accident
Police Attendance
Medical Emergency
Injury
Other:
List of persons witnessing incident:
List the name and role (ie, client, case manager, mental health worker, police) of everyone present at the event or involved in dealing with it. Use full names, for everyone involved in an incident. You may use initials only of clients who witnessed an incident, but were not involved in any way.
Detailed description of incident: (include observations preceding incident, location of incident, actions taken by staff and others)
Describe the event. Just the facts. Describe actions and observations. Write down what was said, if you remember. Do not include interpretations or assumptions. When you include information that you did not personally witness, clearly identify who reported the information to you. (i.e. “John Smith said that he saw Stewart Jones placing something under the couch.”)
Do not include third hand information, or information that you do not attribute to a source. For example: “Everyone was aware of the conflict between Jessie and Pat,” or “Rudy and told Trudy that Jo was not feeling well” unless you witnessed the exchange.
Follow-up
Describe actions performed by staff after incident, follow-up procedures, including reporting to supervisor, police, WorksafeBC.
Describe what you or others did after discovering the incident. This might include calling emergency services, providing first aid, contacting a supervisor, talking to a client in order to help them calm down, cleaning up a spill, etc. Include phone calls made to caregivers, doctors, etc.
You do not need to include completing the incident report form.
Signature of reporting staff:Date:
Reporting This helps you record who you reported the incident to, and when. Always contact your immediate supervisor or designate as soon as possible. They will instruct you as to who else needs to be contacted immediately. Most incidents will not need to be reported to anyone else immediately, but some may. Your involvement in an incident does not end until you have spoken with a supervisor, and completed this report.
To whom was the incident reported? / Name / Time / Date
Immediate Supervisor*:
Director:
Case Manager or other professional:
G.P. or Psychiatrist (in case of suicide)
*Immediate supervisor must be notified in person or by phone as soon as possible
Report received by: / Initial / Date
Service Director:
Executive Director (or designate):
Health and Safety Committee:
Recommendations for corrective action: This area is for recommendations that could prevent future incidents of this type occurring. As the front-line person dealing with an incident, you are in an excellent position to provide practical suggestions for things like training, environmental solutions, and changes in procedures.

Revised: September 2014