Community Care Reportable Incident Form

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All fields are required unless stated

First Name

Last Name

Email Address

Phone (optional)

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Community Care Home Reportable Incident Form

All fields are mandatory as applicable.

Facility Address

Name of person completing this form

Facility Name (as it appears on the Licence)

Phone Number (for follow-up)

The person(s) in care are in:

An IH Owned Bed

An IH Funded Bed

A Private Bed

Other (This is to be used by CLBC or other facilities with beds not funded by IHA)

If the incident is an outbreak or service delivery problem, only indicate the total # of persons in care affected below.

Person in Care Involved	Date of Birth
Person in Care Involved	Date of Birth
Person in Care Involved	Date of Birth
Person in Care Involved	Date of Birth

Total Persons in Care involved

Incident Details

Not Witnessed

Name of other persons involved / witnessed the incident	Indicate if staff, volunteer, family, guardian or visitor
Name of other persons involved / witnessed the incident	Indicate if staff, volunteer, family, guardian or visitor
Name of other persons involved / witnessed the incident	Indicate if staff, volunteer, family, guardian or visitor
Name of other persons involved / witnessed the incident	Indicate if staff, volunteer, family, guardian or visitor

Incident Date (mm/dd/yyyy)

Time

Incident Type (More than one category may be selected) Refer to Residential Care Regulation Schedule D for reportable incident definitions

Details of Incident (what occurred leading up to the incident, details of the incident including location where it occurred, what occurred directly after the incident)

Facility Actions (describe the actions completed in follow up to the incident, including how future risk will be mitigated; i.e. physical repairs, care plan changes, assessments or referrals, etc.)

Transferred to Hospital

Care plan reviewed/revised

Details

Date (mm/dd/yyyy)

Time

Funding Program

Date(mm/dd/yyyy)

Time

Physician/Nurse Practitioner

Date (mm/dd/yyyy)

Time

Contact person or Representative

Date (mm/dd/yyyy)

Time

RCMP/Police

Date (mm/dd/yyyy)

Time

Coroner - for unexpected deaths

Date (mm/dd/yyyy)

Time

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Death
Expected/Unexpected Expected Unexpected
	a) Coroner notification box (as per notification section below)
	b) Is the coroner investigating?	Select Yes or No Yes No

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