FAIRBANKS NATIVE ASSOCIATION

CONSUMER/EMPLOYEE/VISITOR INCIDENT REPORT

Complete and submit Section I to the Program Supervisor and email a copy to the FNA H S Coordinator () within 24 hours. Additionally, the Program Supervisor is to notify appropriate agencies or authorities as required by law, grant, and contract or otherwise.

SECTION I – Description of the Incident

Report submitted by: ______
Title: ______/ Date: ______
Telephone Number: ______/ Extension: ______
Date of Incident: ______/ Time/Shift: ______
Address/Location of Incident: ______

a) Type of Incident (check all that apply):

Abuse/Neglect Medication Error/Issue Requested Transportation

Communicable Disease Obscene/Harassing Phone Call Vehicular Accident/Issue

Elopement/Wandering Possession of Weapons Violence/Aggression/Threatening

Evacuation Sentinel Event Behavior

Facility Equipment Sexual Assault/Assault Other: ______

Injury - Consumer Suicidal Thoughts or Attempt ______(describe)

Injury - Staff

b) Name each person involved in the incident (use initials for consumers(s) if 42 CFR Part 2 applies).

Indicate the role of each person in the incident using the following abbreviations:

C = Consumer E = Employee V = Visitor W = Witness (if not already identified)

Name / Role / Comments/Notes

c) Describe how the incident/event occurred:

d) Name and position of person that was immediately notified:

e) Supervisor’s instruction(s) (if applicable):

Additional Comments:

Signature:______Date: ______

Emailed to H&S (as soon as possible and within 24 hours (Date/Time): ______

NOTE:

If this incident involves an injury to an employee, please have the staff member contact Medcor at 1-800-553-8041.

If this is a vehicular accident, please fill out a vehicle accident report as well.

SECTION II – Department or Supervisor In Charge of Investigation

(Send Section I and Section II to the program safety representative)

1. Was the incident preventable? Yes No If yes, how?

2. Did the employee take action after the incident? Yes No If yes, what action was taken?

3. What action was taken to prevent future similar incidents?

4. What follow up is needed?

5. Who is responsible for follow up?

6. Additional information: (Action taken)

Your Name:______Date: ______

(Please Print)

Your Signature:______

Date & Time Reviewed by Program Director:

SECTION III – Program Health & Safety Representative Review/Follow-up:

IMMEDIATE CAUSES – check all as appropriate
Substandard Acts/Actions
□Operating equipment without authority
□Failure to warn
□Failure to secure
□Operating at improper speed
□Making safety devices inoperable
□Removing safety devices
□Using defective equipment
□Failure to use PPE
□Improper loading
□Improper placement
□Improper lifting
□Improper position for task
□Servicing equipment in operation
□Horseplay
□Under influence of alcohol and/or other substances / Substandard Conditions
□Inadequate guards or barriers
□Inadequate or improper protective equipment
□Defective tools, equipment or materials
□Congestion or restricted action
□Inadequate warning system
□Fire and explosion hazard
□Poor housekeeping, disorder
□Hazardous environmental conditions, gases, smoke, dusts,
fumes
□Noise exposure
□Radiation exposure
□High or low temperature exposure
□Inadequate or excess illumination
□Inadequate ventilation

Comments:

______

Program Health & Safety Representative Date

______

Program Director Date

______

Division Director Date

______

Executive Director Date

______

Health & Safety Coordinator Date

NOTE: Send completed original Incident Report to Health and Safety Coordinator

Incident Report Form Revised September 1, 2016

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