Ocok Serious Incident Report Form Page 2
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2OCOK SERIOUS INCIDENT REPORT
DESCRIPTION OF INCIDENT
(thoroughly describe the nature and circumstance of the incident and include all relevant details; use additional
piece of paper if needed)
INTERVENTIONS
(describe interventions made during and after the incident, such as medical intervention, contacts made, or other follow-up actions;
include names, dates, and times of contacts made to CVS, law enforcement, or other individuals; if any child required medical treatment, document date of the exam,
name of health-care professional, their findings, and any provided treatment; use additional piece of paper if needed)
RESOLUTION TO INCIDENT
(use additional piece of paper if needed)
OCOK INTERVENTIONS AND FOLLOW-UP
(use additional piece of paper if needed)
Report Completed by: ____________________________________
Date: ____________________
Reviewed by Supervisor: __________________________________
Date: ____________________
OCOK Reviewed by: ______________________________________
Date: ____________________
OCOK Reviewed by: ______________________________________
Date: ____________________
Rev. 10-14
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