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 Incident Report Form (All Workplace Incidents, Accidents, Near-Misses, and Exposures)

Purpose: To document all incidents, accidents, near-misses, and exposures promptly, ensuring timely investigation, corrective actions, and compliance with NM regulations and company policy.

Section A: Reporter and Event Details

Date of Report
Month
Day
Year
Date and time of the incident
Month
Day
Year
Time
HoursMinutes
Incident Type (check all that apply):

Section B: Persons Involved

Please list any names involved. If names include an employee from a 3rd party vendor, provide details. If it involves residents family, please provide details such as relationship or the resident (POA, Daughter, son, ect.). If there are no additional names just put "Self"

Was medical attention needed?
Yes
No
Has medical attention been provided?
Yes
No
Were witnesses present?
Yes
No

Please provide contact info if necessary.

Section C: Incident Description

Please give a detailed description of the event that took place. You may also choose to upload your statement instead. If you do just type "Uploaded" into the response box.

In your opinion, list anything that may have caused this event to take place.

Section D: Injury/Exposure Details (if applicable)

If there is no injury or exposure to report please skip this section.

Body Part(s) Injured: (Check All that Apply)

Please provide any details.

Was First Aid Provided:
Yes
No
Not Necessary
Did any person(s) involved in this incident require transportation to a medical facility:
Yes
No
Unknown
Was a Nurse Called?
Yes
No
Unknown
Was the Family Contacted?
Yes
No
Unknown

Section E: Evidence and Supporting Documentation

You are not required but you may upload up to 10 images.

You are not required but you may upload up to 5 statements from individuals involved. Please note any statement uploaded needs to be signed and dated by the individual who wrote it.

You are not required but you may upload up to 5 statements from individuals involved.

Review the information for accuracy, then submit. You will receive a confirmation email within 72 hours of submission. 

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