Additional details
ARE YOU LOGGING THIS INCIDENT ON BEHALF OF ANOTHER
STAFF MEMBER? Tick ✓
YES
NO
RESPONSIBLE SERVICE OR FACILITY - PRINT NAME OF SERVICE OR FACILITY AND
LOCATION
LOCATION INCIDENT OCCURRED Tick ✓
premises Client’s residence Other
CLIENTS INVOLVED PRINT CLIENT NAME
LAST NAME
FIRST NAME
OTHER NAMES
CLIENT NUMBER 6 DIGITS
SOURCE DATABASE
Seniors Services
Selection List Remove
Please include details about the injury [e.g. James: right knee bruised,
Jesse: left hand/ wrist broken, etc]
You can also upload photos and relevant documentation from the
“Supporting Documentation” page.
DESCRIBE WHAT HAPPENED Please provide as much detail as possible about
the incident.
SERIOUS INCIDENT ESCALATION.
DID THE INCIDENT RESULT IN ONE OF THE FOLLOWING SERIOUS OUTCOMES? Tick
✓
YES
NO
WHAT ACTIONS HAVE YOU TAKEN, INCLUDING THOSE TO ENSURE THE HEALTH,
SAFETY
AND WELLBEING OF THOSE INVOLVED OR TO MITIGATE THE RISK? Describe the
actions taken immediately after the incident occurred.
WHO WAS NOTIFIED?
ROLE OF PERSON NOTIFIED
NAME OF PERSON SPOKEN TO
(STAFF)
NAME OF PERSON SPOKEN TO
(NON-STAFF)
DATE NOTIFIED
Add New
ASSESSOR HAS REVIEWED THIS QUASAR INCIDENT REPORT - UIE ASSESSOR TO SIGN
AND DATE
ASSESSOR NAME:
DATE
ASSESSOR SIGNATURE:
