Project Horse Internal Reporting

Equine/Client Incident and Safety Plan Report

Facilitating staff is required to submit this report within 2 business days of incident.

Report Submitted By *

Report Submitted By

First Name

Last Name

Date of Incident *

Date of Incident

MM

DD

YYYY

Time Incident Occurred *

Time Incident Occurred

Hour

Minute

Second

MH Professional #1

First Name

Last Name

MH Professional #2 (If Applicable)

First Name

Last Name

ES Professional #1

First Name

Last Name

ES Professional #2 (If Applicable)

First Name

Last Name

Client Name

First Name

Last Name

Client Age

Client Gender

Briefly Describe Weather and Conditions *

Facility Location Where Incident Occurred *

People Involved (Staff, Volunteers) *

Horses Involved *

Type of Incident *

If "Other" Please Explain Here

Detailed Description of Incident *

Describe Immediate Response to Incident *

What is the Follow-Up Plan and Timeline? *

Please Provide Any Additional Information Desired

Please Check All that Apply Right Now *

Client family member notified

First Aid and/or CPR given

9-1-1 called / professional aid needed

Staff facilitators debriefed & analyzed incident

Follow-Up Plan formulated

Follow-Up Plan is still in-progress

Follow-Up Plan is fully implemented

ADDITIONAL ACTION REQUIRED (notify insurance carrier, follow up with client and/or family again, training program, etc)