AFC - Online Incident / Accident Report Form

Facility Information

Facility Name:

License Number:

Facility Address:

Facility Phone:

Licensee Name:

Person Directly Involved Information

Name of Person Directly Involved:

Relationship Type:

Case Number (if applicable):

Address:

City/State/Zip:

Phone:

Other Person(s) Involved / Witnesses

Name:

Relationship Type:

Name:

Relationship Type:

Name:

Relationship Type:

Name:

Relationship Type:

Facts of the Incident

Date of Incident:

Time of Incident:

Name of Employee Assigned to Resident:

Location of Incident (Kitchen, Yard, etc.):

Explain What Happened / Describe Injury (if any):

Action Taken by Staff/Treatment Given:

Corrective Measures Taken to Remedy and/or Prevent Recurrence

Treating Physician/Health Care/Medical Facility/Hospital:

Physician's Diagnosis of Injury, Illness or Cause of Death, if known:

Phone Number

Date Care Given

Time Care Given

Person(s) Notified

AFC Licensing:

Notification Date/Time:

Written Notice Date:

Adult Protective Services (if applicable):

Notification Date/Time:

Written Notice Date:

Physician or RN (if applicable):

Notification Date/Time:

Written Notice Date:

Office of Recipient Rights (if applicable):

Notification Date/Time:

Written Notice Date:

Office of Recipient Rights (if applicable):

Notification Date/Time:

Written Notice Date:

Responsible Agency:

Notification Date/Time:

Written Notice Date:

Law Enforcement Agency (if applicable):

Notification Date/Time:

Written Notice Date:

Designated Representative / Legal Guardian:

Notification Date/Time:

Written Notice Date:

Other (please specify):

Notification Date/Time:

Written Notice Date:

Signatures

By checking this box and typing my name below, I am electronically signing this form.

Person Completing Report:

Email:

Licensee / Licensee Designee / Administrator:

Email:

COPY DISTRIBUTION: Resident Record, Licensing Consultant, Responsible agency (if required by rule) and Designated representative.

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AFC - Online Incident / Accident Report Form

Facility Information

Person Directly Involved Information

Other Person(s) Involved / Witnesses

Facts of the Incident

Person(s) Notified

Signatures

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