Staff Documentation Protocol:

This report must be completed within 24 hours of the incident, per Affordable Assist policy and Tennessee Code § 68-11-211.
Use objective, factual language. Avoid speculation, assumptions, or emotionally charged descriptions.
Include all relevant details, even if incomplete or pending follow-up.
Ensure all required notifications (e.g., APS, supervisor, family) are documented accurately.
If clarification is needed, refer to the Incident Reporting SOP or contact your supervisor immediately.

This section is intended for internal use only and is not shared with clients or external parties. All documentation is subject to review by authorized regulatory agencies.

Reporter Information

Please provide your name, role, and contact details. This ensures accountability and allows for follow-up if needed.

First Name

Last Name

Role / Title

Date of Submission

Preferred Contact Method

Phone

Phone/Mobile

Incident Overview

Include the date, time, location, and type of incident. This section establishes the context for review.

Date of Incident

Time of Incident

Location

Type of Incident

Type of Allegation

Was anyone injured?

Yes

Immediate Actions Taken

Individuals Involved

Document clients, staff, witnesses, and any external agencies contacted. This supports transparency and regulatory tracking.

Please List all persons involved

Name	Contact Information

Was law enforcement or EMS contacted?

Yes

Agency Name

Case Number

APS Notified?

Yes

Date / Time Notified

Method of Contact

APS Representative Name

APS Case Number

Was a verbal report made within 24 hours?

Yes

Date & Time of Verbal Report

Recipient Name & Role

Method of Contact

Incident Description & Context

Use objective language. Include contributing factors such as environmental conditions, behavioral triggers, or procedural lapses.

Detailed Narrative of the Incident

Contributing Factors & Environmental Conditions

Client Vulnerability & Risk Indicators

This section supports APS reporting and internal risk assessment. Please note cognitive status and vulnerability level.

Client’s Cognitive Status at Time of Incident

Was the client considered vulnerable or dependent?

Yes

Unsure

Known Risk Factors

Was this incident preventable?

Yes

Unsure

Any Disruption to care delivery

Yes

Describe any delays, changes, or interruptions in scheduled care or services.

Notifications

Tennessee law requires verbal reporting within 24 hours for certain incidents. Document all notifications made.

Was the Supervisor Notified?

Yes

Supervisor Name

Time Notified

Family / Guardian Notified

Yes

Family / Guardian Name

Time Notified

Confidentiality Disclaimer

This report is confidential and protected under Tennessee Code § 68-11-211. It is intended solely for internal use by Affordable Assist Private Care and authorized regulatory agencies. Information contained herein is not subject to public disclosure and may only be released in accordance with applicable laws, disciplinary proceedings, or legal mandates.

I affirm that this report is accurate and complete to the best of my knowledge.

Critical Incident Report