Speech Therapy Incident Report Form Template

Client Information

• Full Name: _________________________
• Date of Birth: //_____
• Medical Record Number: _____________

Incident Details

• Date of Incident: //_____
• Time of Incident: : AM/PM
• Location: _________________________

Type of Incident (Check all that apply)

□ Fall □ Choking/Aspiration □ Equipment Malfunction □ Behavioral Incident □ Adverse Reaction □ Communication Device Issue □ Other: _________________________

Incident Description

Detailed account of what occurred:

Immediate Actions Taken

□ First Aid Administered □ Emergency Services Called □ Parent/Guardian Notified □ Physician Notified □ Other: _________________________

Witness Information

• Name(s): _________________________
• Role(s): _________________________
• Contact: _________________________

Follow-up Actions

□ Treatment Plan Modification Required □ Equipment Inspection Needed □ Staff Training Required □ Policy Review Necessary □ Other: _________________________

Additional Notes

Report Completed By

• Name: ___________________________
• Title: ___________________________
• Signature: _______________________
• Date: //_____

Supervisor Review

• Name: ___________________________
• Signature: _______________________
• Date: //_____