Long-Term Care Survey Alert

Tool:

Staff Can Use This Form to Share How They Are Helping Residents

Nursing expert puts a new spin on 'incident report.'

POSITIVE INCIDENT REPORT

Dear Boss:

I'd like to report the following positive experience I just had. I feel good and want to share what happened.

I made a difference in the life of another person when:

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Thanks for listening!

Signature___________________________________

Date__________________

Source: Waugh Consulting, April 2001

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