On-Call Report

On Call will document EVERY Call / Event.

On-Call Critical Log
On-Call Name:

Last

First

Middle
Date:
Time:


AM PM
Location:
Emergency / Event:
Nothing to Report
No Issues

Staffing
Staff Lateness / Staff issue
Staff - No Call - No Show
No Staff Coverage
Staff Injury
Late Pick up from Day Program / job
Medical
Medication issue / Shortage
Pharmacy Call
Missed Medical appointment
Hospitalization / Doctor visit
 
Facility:
Loss of Heat / Air Conditioning (A/c)
Loss of Light / Power Outage
Plumbing / Water issue
Property damage
Alarm - Fire / Property
Transportation
Vehicle Malfunction
Vehicle Accident
Behavioral issue
 
Other
Unexpected Visitor
Missing Property
Neglect / Abuse
Food Shortage
Other
Contacts:
Staffing
SMOD
Manager
Day Program
DDD - Case Manager
Guardian - BGS / Family
Administrator of Residential Services


Medical
Behavior
Facilities / Maintenance
Transportation
Medical
Police / Hospital
OED
Full description of Emergency / Event:
Follow-up Action required:
Who did you contact regarding this issue / Incident:

Full Name


Time of contact

AM PM
ANTI-SPAM
Enter the characters:
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