Date of Incident:                                   

Staff Making Report:                                                                                           

Client Involved in Incident:                                                                                  

Description of Incident:                                                                                        

· Cause:

· Resolution: 

· Is this indicative of a trend?   Yes   No

· Are actions need for improvement?   Yes  No

o       If yes, what actions have been taken?

o       What are the results of the improvements?

· Is additional training needed?    Yes  No

· Can future incidents be prevented?     Yes   No

Date this report was submitted to the Board of Directors: