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Incident & Complaint Reporting

Two separate forms: employee incidents, and patient or facility complaints.

Employee Incident Report

For employee injuries, near misses, and workplace safety events.

Do not include any HIPAA / patient health information on this form. No patient names, initials, dates of birth, addresses, medical record numbers, or diagnoses. If the event involves a patient, use the Patient/Facility Complaint & Investigation form instead.
For any emergency, call 911 first. This form is for internal reporting.