CCA Incident Report

Client / Employee Info

Client Name *

Client Birth Date

Employee / Caregiver Involved

Section 1 — Incident Details

Incident Type

Fall Medication Error Elopement Behavioral Injury Near-Miss Property Damage Abuse / Neglect Other

Incident Type

Severity

Minor Moderate Major Critical

1. Date and Time of Incident

Date of Incident

Time of Incident

2. Date and Time Incident Reported

Date Reported

Time Reported

3. Incident Reported By

Name

Role

4. Incident Reported To

Name

Role

5. Location of Incident

Client's Home Bedroom Bathroom Kitchen Community Medical Facility Vehicle

Location (Address or Description)

6. Other Individuals Involved

List any witnesses, family members, or other staff present.

Name 1

Role 1

Name 2

Role 2

Name 3

Role 3

7. Witness Description of the Incident

Found on floor Reported pain No visible injury 911 called Family notified Refused treatment

Description

8. Did the Incident Result in Injury?

Yes

No

Laceration Bruising Fracture Sprain Head injury Pain only

Describe the injury

Section 2 — Investigation / Findings

9. Supervisor / Investigator Comments and Findings

Comments / Findings

10. Was the Incident Preventable?

Yes

No

Unknown

Fall prevention training Update care plan Increase supervision Med protocol review Home safety assessment

Suggested Corrective Action(s)

11. Was the Incident Reported to an External Agency?

Yes

No

CDPHE APS CPS Law Enforcement Hospital / EMS Insurance Carrier

Name of Agency

Reported by (Name)

Reported by (Role)

12. Agency Manager Review, Comments, and Actions

Manager Review