Incident Report- Shepherd’s Cove

Shepherd’s Cove — Incident Report

Shepherd’s Cove · Community Crisis Services

Incident Report

Complete as soon as possible after any incident. All fields marked * are required. Submitted directly to Shepherd’s Cove management.

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Incident Details

Date of incident *

Time of incident *

Exact location *

Incident type *

🏥 Medical ⚠️ Behavioral 🦺 Safety / Hazard 🔒 Theft / Property 🤜 Conflict 💊 Substance Use 📋 Other

Severity

🟢 Minor 🟡 Moderate 🔴 Serious 🚨 Critical

🚨 Critical incident: Contact your on-call supervisor immediately if you have not already done so.

Person Involved primary subject

Full name *

Date of birth

Gender identity

Status

ResidentVisitorStaffOther

Additional info

Description *

What happened? *

Witnesses

Actions Taken

What did staff do? *

Was 911 called?

YesNo

Supervisor notified?

YesNo

Supervisor name

Time notified

Outcome / resolution

Follow-Up

Follow-up actions needed

Management review requiredCheck if this needs management attention before next shift.

Completed By

Your full name *

Your title / role

Your email

Time completed

Electronic signature *

By typing your name you certify this report is true and accurate to the best of your knowledge.

Shepherd’s Cove · Community Crisis Services, Inc. · Confidential Incident Report