Incident Reporting Form

If you are reporting an injury, accident or property damage where the person affected or responsible was on the clock as a paid employee do the following:

1. Seek appropriate emergency services, as needed.
2. If there is an injury always present the individual with Eggleston’s panel of physician form and secure the affected employees signature(when reasonable).
3. Always notify human resources by phone to coordinate panel of physician services and/or drug/alcohol testing.
4. Do not provide transportation to medical providers.

If you are reporting an injury, accident or property damage where the person involved is an associate and is not engaged in a job-related activity (paid employment) do the following::

1. Seek appropriate emergency services and/or provide basic first aid if needed.
2. Notify your supervisor and the health and safety coordinator by phone.
3. Notify residential providers, Guardian/Authorized Representative and primary emergency contact if needed.
4. Do not provide transportation to medical providers.

If you are reporting an act of abuse, neglect or exploitation involving any person receiving services (Day support, Residential, Employment Services, etc) do the following:

1. If possible, immediately remove the individual from the situation.
2. Seek medical attention or provide basic first aid if needed.
3. Always contact the police.
4. Always contact Adult Protective Services in the locality where the person resides.
5. Always notify the Eggleston human rights coordinator and case manager by phone immediately.