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

First Name

Last Name

Date of Incident

YYYY

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)

Project Horse Internal Reporting

Equine/Client Incident and Safety Plan Report

Project Horse Inc.

CLIENT SERVICES & FACILITY

ADMINISTRATIVE OFFICE