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Medical Incident Report

Your name *

Last name

Email address *

Are you filling out the report for yourself or someone else? *

Myself

Someone Else

Phone Number: *

Person's Address: *

Person's Birthdate: *

Is the person involved under the age of 18 years old? *

No

Yes

Incident Type *

Injury

Illness

Other

Incident Date *

Incident Time *

What time did the incident occur? Please specify AM or PM.

Facility Location of the Incident *

Where did the incident occur?

Incident Details *

Please describe what happened, how it happened, and other pertinent details.

Were there any witnesses or observers? *

No

Yes

Specific Observations/Findings/Assessments *

First Aid Treatment Provided *

Was the person involved instructed to follow-up with a Primary Care Giver? *

No

Yes

Was 911 called? *

No

Yes

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