Vitalis HealthCare Services

Report an incident

If someone is in danger right now, call 911 first. Fill this in afterwards.

What happened?

Choose everything that applies.

Your best judgment is fine.

Write names the way you know them — we will match them to our records.

Client's name

Caregiver or staff member's name

Anyone else who saw it

When did it happen?

Where did it happen?

In your own words. Detail helps — write as much as you need.

What did you do about it?

How was the person when you left or last saw them?

This is one of the first things we are asked in an inspection. Choose everyone who has already been notified.

When were they told?

Anything else about who was told

Were the police or another authority involved?

So we can come back to you with questions.

Your name

Your role

Your email

Your phone number

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Vitalis HealthCare Services · this report goes straight to the office