Staff Incident/Injury Report

MILESTONE, INC.

STAFF INCIDENT/INJURY REPORT

Name of Employee: Facility/Department:

Date of Incident/Injury: Time: A.M. P.M.

Date Reported: Location (room or area) of Incident:

Type of Incident/Injury:

Injury, e.g., bite, bruise Possible injury (fall) Vehicle accident injury Other

laceration no apparent injury or possible injury (Please explain)

Was employee authorized to be at location of injury/incident? Yes No

What was employee doing?

Describe exactly how Incident/Injury happened and what was the cause:

Indicate injury, bruise, etc., by marking with an AX@ on the affected

body location. Give a brief description for each AX@.

Employee: Returned to work Went home Given first aid - type of first aid

given: By whom:

Seen by a physician? Yes No

When Where M.D.=s Name:

At this time, the employee chooses not to be seen by a physician:

Employee Sign Here:

Emergency Services Required: No Yes

Describe:

Medical authorization was given by: Doctor:

to return to work: As tolerated Full duty Light duty

Other:

Witness to the Incident/Injury: Phone Number:

What immediate action was taken to prevent another incident/injury:

PE.43 1/13

In an individual was involved, check the following that apply:

Turning individual Ambulating individual Walking individual

Breaking individual fall Lifting individual in bed/chair Other

Transferring individual from To

If an individual was involved, was individual Cooperative Combative Confused

Agitated Agitated by employee Weak Sedated Stumbled

Non-weight bearing

Equipment being used with the individual: Gait belt Walker Cane

Bath tub Posey vest Lift: type Wheelchair

Shower chair Bed Other:

Was equipment working properly? Yes No: Explain

Did you have assistance? Who?

Did you request assistance? Yes No

If the incident/injury did not involve an individual, what contributed to the incident/injury?

Condition of the floor or area where incident/injury occurred: Wet Icy Cluttered

Hazard unmarked Other

What do you feel contributed to the incident/injury? Object too heavy Haste Object too bulky

Object too high Confined space Rules Employee=s body position

Other

What do you feel you could have done to prevent the incident/injury?

Was safety instruction and body mechanics instruction given to you regarding this type of incident/injury? (e.g. Individual Crisis Management)

Yes No - How long ago? 6 months 6 months - 1 year Don=t know

None given

Identify Supervisor notified: Date: Time:

Identify Nurse/Residential Supervisor/AOD notified: Date: Time:

Report completed by:

Nursing assessment (if applicable):

Nurse=s signature: Date: Time:

Administrative review signature: Date: