Name: Lisa Luther Age: 90

ABUSE INCIDENT REPORT FORMThis form should be used for notification of all instances where there are any suspicions of elder abuseor any unexplained injuries or bruises. These incidents must be reported to the Department of Healthand Ageing and the police within 24 hours of the incident or notification of the incident. Pleasecomplete the form as soon as you are made aware of the incident and contact the Care Manager. DETAILS OF INCIDENTName of Facility       Date of Incident orNotification of Incident       Name of Person reportingthe incident       Time of incident orNotification of Incident       Name of Person Incidentreported to       Date & Time Reported       Date of birth       DETAILS OF RESIDENT OR COMMUNITY CLIENTName of Resident / Client       Medical Diagnosis andrelevant history       Name of Resident’s /Client’sRepresentative MaleFemale GenderDate & TimeRepresentative Notified             DETAILS OF ANY INJURYNature of the Injury       Immediate care given       Name of MedicalPractitioner (MP) notifiedName of Attending PoliceOfficers & police stationName of hospital iftransferred       Date & Time MPattendedDate & Time PoliceattendedDate & Time transferredto Hospital                            DESCRIPTION OF EVENTSFactual description of theincident or allegedincident. Please bespecific, noting times,.(attach a separate sheet ifit is necessary to providemore information)       DETAILS OF WITNESSES (attach written statements)Name      Name       Signature & Designation of Person Reporting Address       Phone       Address       Phone             Date       TO BE COMPLETED BY CARE MANAGERIncident Reported toDepartment of Health and Ageing?Incident Reported toDepartment of Health and Police?Date & Time InvestigationForm completed YesNoYesNo       Date & Time Reported       Date & Time Reported       Signature of Facility Care Manager       Date      

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