Incident Report Form - Prestigious Nursing

Incident Report

This form should be used to report all workplace incidents and should be completed by the employee and sent to Prestigious Nursing within 12 hours of the incident.

Employee Name*
First Last
Phone Number*
Job Title*
Incident Information
Include all details related to the incident, including but not limited to names, positions, times, etc. If Law Enforcement was contacted please include the name of the agency and contact person.
Date of Incident*
MM slash DD slash YYYY
Time*

: Hr

Min

AM/PM
Specific Location of Accident*
Facility Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Description of Incident*
Was medical attention required?*
- Yes
- No
- Yes, but declined to seek treatment
Was anyone injured?*
- Yes
- No
Was the family notified?*
- Yes
- No
Why was the family not notified?*
Who was notified?*
Describe the Injury*
Reporting Information
Who reported the incident?*
First Last
Where or who was the incident reported to?*
What time was the incident reported?*

: Hours

Minutes

AM/PM
Any additional information?*
Acknowledgement*
- I confirm that the above statements are true and correct to the best of my knowledge.
Employee Signature*
First Middle Last
By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Employee Incident Form.
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Incident Report

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