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NERA Online Incident Reporting Form
Please fill all appropriate fields completely and accurately. Describe the incident in chronological order, leaving out opinion or conjecture. Filling out an incident report form is not an admission of guilt, only a formal way to communicate and out of the ordinary event to NERA Management. *** DO NOT INCLUDE ANY PROTECTED HEALTHCARE INFORMATION (PHI) ON THIS FORM **
Your Full Name and EMT Number
*
Date and time incident began:
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Month
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Day
Year
Date Picker Icon
1
2
3
4
5
6
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:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Incident Verbally Reported to:
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Time of First Incident Verbal Report:
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Type of Incident
Vehicle Contact
Employee Injury
Exposure
General Incident
Clinical
Refusal
Facility
Requested
Witnesses to incident: (Full name/Agency Affiliation)
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List of all parties involved: (Full name/Agency Affiliation)
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Full description of what occurred:
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Did anyone suffer a physical injury as a result this event?
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Yes
No
Don't Know
Email
example@example.com
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