Incident Report Form

Use this form to report accidents, injuries, medical situations, or behavioral incidents. (Incidents involving a crime or traffic incident should be reported directly to 360™ and a Police Report filed). If possible, this report should be completed within 24 hours of the event. Submit completed forms to the 360™ corporate office.

Driver/Patient Info

First and last name of driver involved

Phone

First and last name of passenger involved

Phone # of passenger involved

Facility name where passenger resides if applicable

Phone # where passenger resides

Information About the Incident

Date of incident

Month

Day

Year

Time

HoursMinutes

Was EMS notified?

Yes

Location of incident

Description of incident

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible (attached additional sheets if necessary)

Where their witnesses to the incident?

Yes

If "yes", what is witnesses name and phone #

Describe any help that you received from witnesses.

Police Notified?

Yes

Was the individual injured?

Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).

Was medical treatment provided?

If yes, who provided treatment?

Where was treatment provided?

Signature of Driver

Signature of driver

Signature field is empty.

Date

Month

Day

Year

Welcome to 360 Quality Care + Transport Services

High Quality ~ Reliable and Timely ~ First Class ~ Door thru Door
Wheelchair ~ Assisted Ambulatory ~ Stretcher

Driver/Patient Info

Information About the Incident

Signature of Driver