This incident report form is designed for confidential reporting of concerns related to Assertive Community Treatment program fidelity in behavioral health settings. It supports anonymous submissions about service delivery, staffing, documentation practices, evidence-based care, organizational structure, and client safety so teams can review issues consistently and take appropriate next steps.
The template includes focused prompts for the date of the observation, the ACT team or location involved, the primary type of concern, and a detailed description of what was observed. It also gives respondents a way to connect the issue to a specific fidelity standard, note whether supporting documentation exists, and describe how the concern may affect client outcomes or safety.
Because the form captures frequency, impact level, and outcome-monitoring concerns in a structured way, it is useful for internal review, quality improvement, and compliance oversight. Teams can adapt the wording to match their reporting process while keeping the core structure needed for a strong incident report form.
