Incident Report Form — Roots to Recovery

R2R-ID of the resident involved *

This form is completed in respect of any incident that involves a Resident, a staff member, a contractor, a visitor or the property of the Facility. It is completed contemporaneously where possible, and in any event within 24 hours of the incident. Relapse incidents are reported on the separate Relapse Incident Report Form, in addition to this form where required.

SECTION A — INCIDENT DETAILS

Incident Reference NumberDate of IncidentTime of IncidentExact Location on the PremisesWeather / Environmental Conditions (if relevant)

Type of Incident (tick all that apply)

☐ Medical event / illness
☐ Injury (Resident, staff, visitor, contractor)
☐ Medication-related incident
☐ Suspected substance use or intoxication
☐ Refusal to test or tampering with a sample
☐ Verbal aggression
☐ Physical aggression
☐ Threats of violence or harm
☐ Theft or alleged theft
☐ Damage to property
☐ Breach of House Rules
☐ Late return / absconding
☐ Visitor incident
☐ Fire, evacuation or safety alarm
☐ Security incident
☐ Vehicle incident
☐ Death or critical event
☐ Self-harm or suicidal ideation
☐ Other (specify)

If "Other", describe

SECTION B — PERSONS INVOLVED

Primary Resident Involved

Full NamesIdentity Number / Resident ReferenceRoom NumberResponsible Person Name and Contact

Other Persons Involved (Residents, Staff, Visitors, Contractors)

Full Name	Role (Resident / Staff / Visitor / Contractor)	Contact Number	Involvement

Witnesses

Full Name	Role	Contact Number	Brief account

SECTION C — DESCRIPTION OF THE INCIDENT

Provide a factual, chronological description of the incident. Use plain language. Distinguish what was observed from what was reported. Avoid speculation or opinion.

______________________________________________________________________________________________________________

SECTION D — IMMEDIATE ACTION TAKEN

Describe what was done at the scene, by whom, and in what order. Note the time of each action.

______________________________________________________________________________________________________________

Persons notified

Facility Manager (time)Responsible Person (time)Emergency Doctor / Ambulance (time)Certified Homeopath (time)Pharmacist (time)South African Police Service (time)Other emergency services (time)

SECTION E — INJURIES OR MEDICAL CONSEQUENCES

Nature and extent of any injury (Resident)Nature and extent of any injury (Other)First aid administeredMedication administered (if any) and by whomTransported to a medical facility (Yes / No)Facility transported toMode of transport (ambulance / private)Time of transport

SECTION F — PROPERTY AFFECTED

Property Affected	Owner	Nature of Damage / Loss	Estimated Value (R)	Action Required

SECTION G — CROSS-REFERENCES

Drug Testing Logbook reference (if applicable)Medication Register reference (if applicable)Personal Property Register reference (if applicable)Relapse Incident Report Form reference (if applicable)Disciplinary file reference (if applicable)

SECTION H — INITIAL ASSESSMENT

Severity (Low / Medium / High / Critical)Risk of recurrence (Low / Medium / High)Immediate risk to others (Low / Medium / High)Likely root causeContributing factorsRecommended follow-up

SECTION I — COMPLETED BY

Staff Member (Full Name)PositionSignatureDate and Time of Completion

SECTION J — FACILITY MANAGER REVIEW

Manager's findingsDisciplinary action recommended (if any)Operational improvements recommendedCommunication plan (who is informed of the outcome)Manager (Full Name)SignatureDate

SECTION K — CLOSURE

Date ClosedClosed By (Full Name)SignatureLessons recorded in operational learning log