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INCIDENT/COMPLAINT REPORT - Employee
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INCIDENT/COMPLAINT REPORT - Employee
EMPLOYEE: Return this COMPLETED FORM to your SUPERVISOR as soon as possible.
Name of Person Involved
Address:
City:
Phone Number:
Age:
DOB:
Sex
Female
Male
SSN#
Date of Incident:
Time:
Exact Location of Incident:
Check Type of Accident:
Clerical/Data Entry
Communications
Exposure to Hazardous Substance
Medical Device Failure
Medication Error (Wrong: Route, Dosage, Medication, Schedule)
Needlestick
Policy/Procedural Violations
Policy/Procedural Violations
Result reporting
Safety
Testing Process
Vehicle Accident
Check
Other
Staff/Faculty
Student
Visitor
Volunteer
EMPLOYEE:
No
Yes
Were they doing their regular job duties:
No
Yes
Observed by employee
New Value
Yes
Hire Date
Marital Status
Situation observed only by employee
Yes
Employee Title
Protective Equipment being used:
No
Yes
If not used, Why:
Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events, personnel involved, body part injured, reason incident occurred) (If medication error include brand name, manufacturer, dosage) (Use additional form if necessary)
Actions Taken by Staff Members:
1st Witness Name:
Witness Phone Number:
Witness Address:
2nd Witness Name:
Contact Number:
Witness Address
3rd Witness Name:
Preferred Phone Number:
3rd Witness Address
MEDICAL FOLLOW-UP: Was Medical Attention Sought
No
Yes
Treatment Refused
No
Yes
First Treatment Date:
Treating Physician:
Phone Number
Physician Office Address:
First Day Off Work:
Return to Work Date:
Duties Restricted:
No
Yes
Explain:
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