Incident Report Form

ATTACHMENT Z

Incident Report Form

Children’s Health after the Storms (CHATS)

Incident Report Form

Should you or a study respondent become distressed or find the need to initiate emergency protocols during the course of an interview or health assessment, you must complete this form to document the incident.

If you have questions regarding the form’s completion, please call [Insert name] at 1-xxx-xxx-xxxx. Use the back of this form if more space is needed to record details of events or actions.

This form must be completed immediately following the incident and the information submitted electronically via e-mail to [Laura Strange, your Field Supervisor, QA Team, and Field Director] within one (1) working day of the incident. To protect respondent privacy, please only refer to the respondent by their case ID number and do not use respondent names in e-mail exchanges. This completed hard copy form should be shipped to RTI with the completed case records for this household.

Date of Event: ___ ___ /___ ___/___ ___ ___ ___

Time of Event: ___ ___:___ ____ AM/PM

Case ID Number: ___ ___ ___ ___ ___ ___ ___ ___

Location of Event:

Names and job titles of study staff involved with this event:

Description of event:

Description of actions taken by study staff in response to event:

Description of any deviations from approved data collection procedures:

Signature of staff reporting event:

Date event reported to project staff: ___ ___/___ ___/___ ___ ___ ___

Time event reported to project staff: ____ ____:____ ____ AM/PM

Incident Report Form Z-3