incident-report – Hold My Hand Inc

Incident Report Form

Hold My Hand Inc — MN DHS 245D Compliance

🚨 Emergency: If this incident involved immediate danger, call 911 first, then notify your supervisor or on-call staff.

Employee Name *

Employee Phone *

Employee Role / Position *

Person Served (Initials Only) *

Date of Incident *

Time of Incident *

Location of Incident *

Type of Incident *

Detailed Description of Incident *

Immediate Actions Taken *

Was 911 or Emergency Services Called?

Supervisor / On-Call Notified *

Additional Notes

⚠️ Do NOT include full client names, SSN, DOB, or medical diagnoses. Use initials only.