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Report of an Incident
Please complete this form and submit it:
Superior Human Services, Inc. Report of an Incident
Date of Report:
Time of Report:
Consumer Involved:
Below, please write a detailed description of exactly what happened and any circumstances which may have caused the incident.
**Please only note the times in which you had hands on the consumer**
Restraints Used:
Start Time:
Stop Time:
**Please only note the times in which you had hands on the consumer**
Restraints Used:
Start Time:
Stop Time:
**Please only note the times in which you had hands on the consumer**
Restraints Used:
Start Time:
Stop Time:
**Please only note the times in which you had hands on the consumer**
Restraints Used:
Start Time:
Stop Time:
**Please only note the times in which you had hands on the consumer**
Restraints Used:
Start Time:
Stop Time:
Total Restraint Time:
Witness(es):
Person Writing the Report:
Any additional info that may need to be kown:
Verification
Please enter any two digits with no spaces (Example: 12)
*
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