Employee Incident Report Form

Events or allegations of injury, illness, or property damage, including employment and issues with directors and offcers.

WHAT COMPANY / BUSINESS UNIT ARE YOU ASSIGNED?

WHAT COMPANY / BUSINESS UNIT ARE YOU ASSIGNED? M & M HOME CARE SUPPORTIVE HOME HEALTH CARE KNEADED RELIEF MASSAGE & SPA AICM-MICHIGAN
REPORTING PERSON REPORTING PERSON First Last
INCIDENT DATE: INCIDENT DATE: / MM / DD YYYY
INCIDENT TIME: INCIDENT TIME: : HH MM AM/PM
WAS A PATIENT / CLIENT INVOLVED?

WAS A PATIENT / CLIENT INVOLVED? YES NO
WERE OTHER INDIVIDUALS INVOLVED?

WERE OTHER INDIVIDUALS INVOLVED? YES NO
APPROXIMATE LOCATION
PATIENT / CLIENT INVOLVED
PATIENT / CLIENT NAME PATIENT / CLIENT NAME First Last
OTHER INDIVIDUALS INVOLVED
OTHER INDIVIDUAL OTHER INDIVIDUAL First Last
OTHER INDIVIDUAL OTHER INDIVIDUAL First Last
NOTIFICATIONS
WAS THE OFFICE NOTIFIED?

WAS THE OFFICE NOTIFIED? Yes No
NAME OF ADMINISTRATOR NOTIFIED NAME OF ADMINISTRATOR NOTIFIED First Last
TIME THAT ADMINISTRATOR NOTIFIED TIME THAT ADMINISTRATOR NOTIFIED : HH MM AM/PM
WAS EXTERNAL MEDICAL TREATMENT REQUIRED?

WAS EXTERNAL MEDICAL TREATMENT REQUIRED? Yes No
SUMMARY
PLEASE PROVIDE A BRIEF DESCRIPTION OF WHAT HAPPENED:
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