Incident Report
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Time Made Aware of Incident
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (Facility)
*
Athens
Chattanooga
Cleveland
Cookeville
Crossville
Dayton
Dunlap
Franklin
Gallatin
Hartsville
Hendersonville
Jasper
Lafayette
Lebanon
Livingston
Madisonville
McMinnville
Murfreesboro
Rockwood
Smyrna
Tracy City
School Based
VBH Group Home
Other/Community
Program
*
Please Select
Outpatient - CM
Outpatient - MAT/IOP
Outpatient - Other
HUB Program/Unit
*
Please Select
24/7 CSU/Detox
24/7 Observation
24/7 Walk-in Center/Crisis
24/7 Other
Outpatient - CM
Outpatient - MAT/IOP
Outpatient - Other
Explain 24/7 Other
*
Explain Outpatient Other
*
VBH Group Home
*
Bluff Springs (McMinnville)
Brookview (Pikeville)
Donlyn (Chattanooga)
Grubb (Chattanooga)
Hilltop (Cleveland)
Magnolia (Cleveland)
Mountainside (South Pittsburg)
Ridgecrest (Monteagle)
Sabrina (Chattanooga)
Walden (Chattanooga)
School Based Program Name & Location
*
Incident Effecting
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to VBH
*
Client
Staff
Vendor
Visitor
Medical Record Number
*
Others Involved/Witness 1
First Name
Last Name
Address 1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email 1
example@example.com
Phone Number 1
Please enter a valid phone number.
Format: (000) 000-0000.
How involved 1
*
Other Involved/Witness 2
First Name
Last Name
Address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email 2
example@example.com
Phone Number 2
Please enter a valid phone number.
Format: (000) 000-0000.
How Involved 2
*
Other Involved/Witness 3
First Name
Last Name
Address 3
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email 3
example@example.com
Phone Number 3
Please enter a valid phone number.
Format: (000) 000-0000.
How Involved 3
*
Type of Incident (check all that apply)
*
Animal Bite
Assault
Auto Accident
Drug Overdose
Elopement
Environmental Condition
Homicide Attempt
Medication Error
Near Miss Medication Error
Property Damage
Psychosis / Mental Health Condition
Safety Concern
Sharps Injury / Needle Stick
Slip / Fall
Suicide Attempt / Superficial Self Harm
Theft
Therapeutic Hold / Restraint
Unknown
Other
Describe the Incident
*
Objective Statement of Facts Only - no accusations, assumptions, nor opinions
Type of Injury / Damage (check all that apply)
*
Abrasion / Scratch / Cut
Fracture / Break
Sprain / Strain
Contusion / Bruise
Property Damage
Other
None / N/A
Treatment Offered
Yes
Yes - Declined/Refused
No
Not Medically Necessary
Explain Property Damage
Explain Other
Actions Taken (check all that apply)
*
Contacted HR
Contacted Supervisor
Contacted Crisis for Assessment
Contacted Police
Notified Nurse / Provider
First Aid Provided by Staff
Referred to Outpatient Provider
Transported to ER
Admitted to VBH 24/7 Program
No Intervention Needed
Contacted Emergency Contact
Other
Name of Emergency Room/Department
Who Transported
Ambulance
Friend/Family
Police
Self
Type of Outpatient Provider
VBH CM
VBH Med Provider
VBH Therapist
Non-VBH MH Provider
PCP
Other
Further Explanation of Action(s) Taken
Submit addendum email and supporting documentation to Risk Management if results are unknown at time of submitting report
Upload Any Relevant Documentation
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Form Completed By
*
First Name
Last Name
Position
*
Job Title
Date Completing Form
*
-
Month
-
Day
Year
Date
Time Completing Form
*
Hour Minutes
AM
PM
AM/PM Option
Supervisor Name
*
First Name
Last Name
Enter Supervisor Email Address
*
example@example.com
Submit
Should be Empty: