Fresno Yosemite Health Care, Inc
Incident Report Form
Section 1: Scene Information
Who was involved in the incident
Office Employee
Field Employee (Caregiver, CNA, HHA)
Date of Report:
*
-
Month
-
Day
Year
Date
Date of Incident:
*
-
Month
-
Day
Year
Date
Time of Incident:
*
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Incident Location:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip (if unknown - n/a)
Employee Name:
*
First Name
Last Name
Employee Job Title:
*
Employee Phone Number:
*
Case Manager Name:
*
First Name
Last Name
Incident Type
*
Patient Incident
Employee to Employee Incident
Other
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Section 2: Bodily Injury
Did the anyone sustain injuries beyond first aid?
*
Yes
No
Did the anyone need medical attention?
*
Yes
No
Type(s) of Injury:
*
Abrasion
Amputation
Bruise/Contusion
Burn
Chipped Tooth
Cut/Laceration
Fracture
Puncture
Sprain/Strain
Other
Body Part(s) Affected:
*
Head/Face
Neck
Shoulder(s)
Arm(s)
Elbow(s)
Hand(s)/Finger(s)
Upper Back
Lower Back
Abdominal
Hip(s)/Leg(s)
Knee(s)
Ankle(s)
Foot/Toe(s)
Other
Injury Description:
*
Please describe in detail the injury(s) you sustained.
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Section 4: Witness Information
If there were no witnesses, please hit "Next" to continue.
Witness #1:
First Name
Last Name
Email Address
Phone
Witness #2:
First Name
Last Name
Email Address
Phone
Section 5: Incident Statement
In your own words, please describe in detail how the incident occurred:
*
Please upload photos of the incident, incident location, and any relevant documentation:
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Which of the following factors contributed to the incident? (select all that apply)
*
Failure to Lockout/Tagout
Failure to Secure
Horseplay
Improper Personal Protective Equipment (PPE)
Improper Procedure
Inadequate Training
Mechanical Failure
Overexertion
Poor Housekeeping
Poor Maintenance
Slip/Trip/Fall
Spill Release
Unsafe Act
Unsafe Condition
Unsafe Equipment
Weather/Temperature
Other
Please explain in detail the determined root cause of the incident:
*
Reporting Person's Name:
*
First Name
Last Name
Date
I declare that the foregoing is true and correct to the best of my knowledge:
*
Submit
Should be Empty: