Incident Report Template (Blank)

Print this page and fill it in by hand, or fill the on-screen version on our Facing an Incident page and save it as a PDF. This form is about safety and clear memory — not blame. Write what you know; leave fields blank if you’re unsure.

You did the right thing by reporting this. If you’re shaken, that’s normal. Take your time.

1. Who is filling this out?

2. When and where did it happen?

3. Who was involved?

4. What happened?

Write what you saw and heard, in plain words. Stick to the facts — what was said or done, not what you think someone meant. Quote exact words if you can. Note if it was about sexual orientation, gender identity, gender expression, or something else.

5. What did you do right away?

Even small actions count — a calm word, checking on someone, moving a person to safety. If you didn’t know what to do, write that too.

6. Was anyone hurt or unsafe?

7. Who have you told?

List anyone you notified — charge nurse, Director of Care, administrator, family. If you haven’t told anyone yet, write who you plan to tell next.

8. What happens next?

Store this with your usual incident records. Follow your home’s reporting chain and any provincial mandatory-reporting steps. In Ontario, certain incidents must be reported to the Ministry of Long-Term Care — flag it to your administrator so nothing is missed.