1. Instructions for completing an incident report
Incident Reports
Instructions for completing an incident report
9/18/17

2. Complete an Incident Report For:
Significant destruction or loss of property
Inappropriate behaviors that
are new
result in injury to self or others
create a potentially dangerous situation
behaviors that are out of the ordinary or are not documented on behavioral data sheets
Bullying or potential bullying situations
Whenever the health, safety or rights of a student could be in danger through the actions of anyone outside Perkins School for the Blind.
If in doubt, check with your supervisor to determine if an incident report must be completed
_______________________________
Incidents are about students, not staff. If staff are injured they must complete a separate staff injury report that is submitted to Human Resources 22

3. When do you not need to complete an incident report ?
Minor bumps or falls with no immediately obvious injury, including falls that are partially blocked
Emotional incidents such as verbal, emotional, or behavioral outbursts without injury to self or others, or significant property destruction
Behavioral incidents that are documented on data sheets unless there is injury to self or others
Check with your supervisor to determine if alternative documentation is required such as behavioral data sheets, seizure records, or documentation in communication logs

4. Complete the Top of the Incident Report Form
Student Full Name
Date / /
Program
Location of Incident
Time AM/PM
Student Name: Full Name
Date: include month/date/year
Time: indicate AM or PM
If you are not sure when the injury occurred, indicate the time it was first seen
Program: Secondary, Lower School, ELC, DeafBlind, Outreach, if other please specify
Location of Incident: be specific, indicated place incident occurred or indicate unknown if not known

5. Description of the Incident
Describe the Incident and Any Injuries Sustained
What happened, what caused the injury, antecedent to the behavior, contributing factors to the incident
Type of Injury: Bruise (no open areas of skin), abrasion (skin is open and rubbed off) cut, swelling, redness
Size: be specific such as ½ by 1 inch, quarter sized, avoid words such as large or small
Location of Injury: parts of the body, include right or left side, note on body chart on the back of the report
Described what you witnessed and what you did
Do not write assumptions or opinions

6. What if more than one student was involved?
Create separate reports for each student
If one student involved has a behavior data sheet for documentation of behaviors an incident report may not be required for that student
Only the name of student for whom the incident report is being written should be included. Do not put in other student names.

7. Human Bites
For Bites ONLY: ☐ Not Applicable Was the skin broken ☐ yes ☐ no Was there bleeding ☐ yes ☐ no
If yes to either question contact Nursing Staff
May be a bloodborne pathogen incident for both the person doing the biting and the person bitten
Indicate if the skin was broken or if there was bleeding
Regarding Students involved: notified the Program Nurse or Nurse On-Call
Regarding Staff involved: notified the Occupational Health Manager or Human Resources

8. Who do you need to contact?
Depending upon the situation you may need to contact one or more of the following people:
Your supervisor
The Program Nurse or Nurse On-Call
The Student’s Behaviorist or Psychologist
The Student’s Parent or Guardian
The AEC

9. Documentation of your contacts
Behavioral Incidents Only: Was Behaviorist Notified ☐ yes ☐ no ☐ does not apply
Was Incident Reported to Program Nurse or Nurse On-Call : ☐ yes ☐ no ☐ does not apply
If yes: Name of Nurse: by: ☐ conversation ☐ voice mail left ☐ sent
What were the instructions given:
Complete Body Chart on back for all injuries or potential injuries.
Report to Parents/Guardian:
Staff contacting parent/guardian (print name)
Parent/Guardian reported to:
Reported by: ☐ conversation ☐ voice mail left ☐ sent ☐ home communication log
Date Reported to Parents/Guardian:
Parent/Guardian Response:
Complete all sections
Check all appropriate boxes
Indicate the name of nurse you contacted
Include details of instructions given by the nurse
Indicate name of parent/guardian you contacted
Include parent/guardian response

10. When to Complete an Incident Report ?
Incident Reports must be completed as soon as possible before the end of the shift
Incidents involving a runaway, filing a 51A, or injuring requiring emergency room or hospitalization must be reported immediately to Residential Supervisor, Assistant Education Director, Education Director or AEC.
A Form 2 must be completed within 24 hours for Massachusetts students regarding incidents requiring emergency room care for injuries or new medical conditions occurring during school hours

11. Questions: Ask your Supervisor
or the Incident Coordinator for your program
Incident Report Coordinators
Secondary: Rachel Dubuque
Lower School and ELC: Elizabeth Torrey
DeafBlind Program: Karen Hern