Incident Report

First Report of Injury / Incident

If this is a medical emergency, please dial 911.
This form will be sent to the hospital administrator. If you need immediate assistance, please go to the closest urgent care at

AtlantiCare Urgent Care Galloway: 110 E Jimmie Leeds Rd, Galloway, NJ 08205
Name of Employee Injured*

First NameLast Name
Employee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Hire Date:

MonthDayYear
Date
Date of Incident:

MonthDayYear
Date
Time of Injury / Incident:

:HourMinutesAM/PM Option
Time Injury / Incident was Reported to Supervisor:

:HourMinutesAM/PM Option
Injury Reported to: *

First NameLast Name
Type of Incident:*

Accident / InjuryProperty DamageBoth Injury and Damage to propertyInjury to Other (Customer)
Details of Incident(part of body/which equipment affected/how did it occur): *

0/0
If related to a patient, please provide patient details and ID:
Description of Injury in Detail:
Please specify body part (left or right)
Witness(es) (If none, write "None"): *
Address Injury / Incident Took Place:*

Street Address

Street Address Line 2

CityState

Zip Code
Was First Aid provided to Injured Person?*

YesNoRefusedN/A (Property Damage only)
Injured Person was treated by:*

EMS / Ambulance / First ResponderEmergency RoomBoth of the aboveUrgent CareN/A (Property Damage only)
Were the Police called?

YesRefused by CustomerN/A
Did you call the Nursing Line with Nationwide?

YesNo
Please let us know the name of the representative you spoke with from Nationwide:
Claim Number
Were you instructed to seek treatment?

YesNoN/A
If so, please provide the facility name and address:
Any Photos You Would Like to Include?
Photo 2
Please give all discharge paperwork to the hospital administrator to retain for your file.
Should be Empty:

First Report of Injury / Incident