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5
New Incident/Accident Report
New Incident/Accident Report
New Incident/Accident Report
Form completed by:
(Required)
Email of staff member completing the form:
(Required)
Email for the direct supervisor of staff member completeing the form:
(Required)
Date Form Completed:
(Required)
MM slash DD slash YYYY
Date of Incident/Accident:
(Required)
MM slash DD slash YYYY
Time of Incident/Accident:
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Program:
(Required)
Early Childhood Services
Community Services
BEST
Administration
Location of Incident/Accident:
(Required)
CRC
Bridge
SFRC
LFRC
HFFRC
RFRC
School 12
School 2
Hoosic Valley
Rensselaer
Admin
TFRC
5th Ave
In the Field
Incident/Accident Type:
(Required)
Serious Incident
Serious Injury
Serious Condition
Suspected Child Abuse or Neglect
Hospital Transport
Medication Error
Food Allery Exposure
CEO Code of Conduct Violation
CEO Zero Tolerance Violation
Staff Accident
Child/Customer/Guest Accident
Vehicle Accident
Involvement in Legal Proceedings
Death
Stating facts, describe the incident:
(Required)
Please include a description of the events that occurred prior that may have caused the incident or accident. Include names of the people involved, if applicable.
Number of staff Involved:
Names and Roles of Staff Involved:
Number of Children Involved:
Name(s) of Child(ren) Involved:
Number of Non-Staff Adults Involved:
Names and roles of Non-Staff Adults:
Please upload any relevant documents to this incident:
(Required)
Max. file size: 512 MB.
Including incident observation forms, ECS incident report, etc.
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