Incident Reporting Form

Incident Reporting Form

To be used for reporting incidents or occurences
Type of Incident *

Exposure Fleet/Building Incident Equipment Incident Personnel/Injury Incident Clinical Notification Safety Notification Compliance HR Report Near Miss/Unusual Occurrence
Your Email Address (Fill in your name) *
example@example.com
Date of Incident *

Month Day Year
Time of Incident (If Applicable)

: Hour Minutes AM/PM Option
Dispatch Incident Number
Individuals Involved (select all that apply)

InCharge Attendant Supervisor Student
In-Charge Name

First Name Last Name
Attendant Name

First Name Last Name
Supervisor

First Name Last Name
Other Person 1

First Name Last Name
Other Person 2

First Name Last Name
Other Person 3

First Name Last Name
Equipment incident

Lost/Missing Equipment Damaged Equipment Medical Equipment Failure Critical Mechanical Failure
Please do not include patient names. Only Incident Numbers are required
Equipment Model and Serial Number *
Notification Type *
Incident Events/Details *
Location of Incident
Witness Name

First Name Last Name

Witness #2 Phone

Area Code Phone Number
Unit Involved
Report Completed By *
Incident Reported To
Supporting Document 1
Supporting Document 2
These are generally the appropriate primary individuals to send incidents to. Also, please include any supervisors/individuals involved or needed to be included according to the incident:

Operations: Brian Bayani

HR: Stefany Smith

Compliance: Chelsea Ellis

Safety: Jeff Perez

Controlled Substances: Mike Hill

Clinical: Eric Steffel / EdDelany

Infrastructure/Building: Trae Gammon

Mobility: Marco Kimassi
Who does this incident report need to be emailed to? Select all that apply. **THIS INCIDENT REPORT WILL ONLY BE SENT TO WHO IS SELECTED** *

Brian.Bayani@nwcommunityhealth.org Ed.Delany@nwcommunityhealth.org Stefany.Smith@nwcommunityhealth.org Eric.Steffel@nwcommunityhealth.org Mike.Hill@nwcommunityhealth.org Patrick.Casey@nwcommunityhealth.org Jeff.Perez@nwcommunityhealth.org Alfred.Perez@nwcommunityhealth.org Anthony.Bohn@nwcommunityhealth.org Marco.Kimassi@nwcommunityhealth.org Morgan.Hunt@nwcommunityhealth.org Chelsea.Ellis@nwcommunityhealth.org
Were there injuries? *

Yes No
Did anyone seek medical attention?

Yes No
Describe the medical attention sought.
Have you completed a repair/request Jot Form

Yes No
Should be Empty: