Empathy Program Incident Report Form printable pdf download

Empathy Program Incident Report Form

EMPATHY Program Incident Report

* Complete a separate form for each incident, within 3 days of the incident occurring.

* Remember that failure to report an incident could result in someone else being put

at risk in the future.

This form should be used for each occasion of



Aggressive behaviour



Verbal abuse



Destruction of equipment or property (or threats of)



Physical assault (or threats of)

Name of person completing the form: ______________________________________

Position title:__________________________________________________________

Date of incident : _________________

Time: _______________ am/pm

Location of incident: _____________________________________

What was taking place when the incident occurred? __________________________

____________________________________________________________________

Other persons present at the time:________________________________________

Name of perpetrator if known, or description if unknown: ______________________

____________________________________________________________________

Was the perpetrator



A friend of a young person



-partner of a client



nteer



 Other

____________________________________________________________

Empathy Program Incident Report Form