Incident-report - Kaleidoscope ABA Therapy Services

Submit An Incident Report

(For Use by Kaleidoscope ABA Staff Members Only)

Kaleidoscope ABA is committed to a safe, ethical and compliant workplace. To report an incident, injury, violation or unusual event, please submit this form. Staff members using this form may choose to remain anonymous. Although providing contact information will improve our ability to respond to properly and fully address the report.

Please choose below:*
I would like to submit an incident report.I would like to submit an anonymous incident report.

Name of Staff Member Making Report*

Contact Phone Number*

KFSABA Work Email Address*

Report Type*

Report Category/Code*

Client Involved
Staff Involved
Guardian or Outside Party Involved
Date of Incident*
Time of Incident
Witnesses
Center Location*
Description*