Fillable Online Incident Report Form with Instructions - 5.4.18 ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Reporting Information section. Clearly indicate the type of incident, such as patient death or ambulance transport, and provide the date and time of the incident.
3. In the Facility Information section, enter your facility's license number, provider number, address, and contact details accurately to ensure proper identification.
4. For the Summary section, succinctly describe what occurred during the incident, including who was involved and immediate actions taken.
5. In the Narrative section, detail your investigation findings and outline steps you will take to prevent similar incidents in the future.
6. Complete the Treatment Information section by checking relevant service types and access types. Attach copies of treatment sheets as required.
7. Finally, ensure that a supervising nurse signs and dates the report before submitting it via fax or mail as instructed.

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