Critical Incident Reporting Form

Property Details
Property Name: Property Location: Commented [CH1]: Can this be a drop down box?
Property Manager Residence Manager: Commented [CH2]: This box isn’t needed
Telephone (mobile): Telephone (mobile): Commented [CH3]: This box isn’t needed- but do
need name of person reporting incident
Email:
Commented [CH4]: These aren’t needed

Incident Details Commented [CH5]: Can this be auto populated so it

emails me?
Date of Incident: Time of Incident:
Location of Incident:
CATEGORY OF INCIDENT: Commented [CH6]: Drop down- with all the categories
listed
Date Property Manager notified:
Commented [CH7]: Yes/No drop down
Date Parents/Guardian notified (if applicable):
Formatted: Indent: Left: 0"

Description of the Incident (Clearly mention what happened, who all were affected and Commented [CH8]: Yes/No drop down

prima facie what caused the incident

Actions Taken (Fill Appropriate)

Issuance of warning to the resident(s) Date: Commented [CH9]: Yes/No drop down box needed
instead of date
Imposition of fine of a stipulated amount Date:
Counseling sought/provided Date: Commented [CH10]: Yes/No drop down box needed
instead of date
Health and safety services sought Date:
Commented [CH11]: Yes/No drop down box needed
Suspension/expulsion from the residence Date: instead of date
Staff disciplinary action taken Date:
Commented [CH12]: Yes/No drop down box needed
Other action(s) taken (please specify): Date: instead of date
Commented [CH13]: Yes/No drop down box needed
instead of date
Commented [CH14]: Yes/No drop down box needed
instead of date
Commented [CH15]: Free text comment box needed
Actions taken to mitigate incident happening in the future

CRITICAL INCIDENT REPORTED BY: Date:

Name: Position:
CRITICAL INCIDENT VALIDATED BY: Date:
Name: Position:
CRITICAL INCIDENT VALIDATED BY: Date:
Name: Position:

Commented [CH16]: Auto populate Incident number

and time and date in Internal Use only box

Thank you for completing the Critical

Incident Report.

INTERNAL USE ONLY

Incident Related References:
Number: Position:
Staff Name: Time Received:
Date