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Home
Apply
Job Search
Staff
Clients
About Us
Contact Us
Resources
Employee Portal User Guides
Timekeeping Instructions & Timesheets
View Your Pay Stubs
Reference & Evaluation Forms
Submit a Reference or Evaluation
Refer a Friend
Incident Report Form
Submit an Incident Report
Sample Resume
Search Contract Jobs
Search Per Diem Jobs
Lifeline Employee FAQ
Travel Nursing & Pay FAQ
The Joint Commission
Education Resources
Customer Feedback Form
Log In
Submit an Incident Report
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Submit an Incident Report
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This form should be used to report all workplace incidents (Patient Safety Incidents, Health & Safety Incidents, Data Protection Incidents, Near Miss) and should be completed by the employee and sent to Lifeline within 24 hours of the incident.
Employee Name
*
Employee Phone Number & Email
*
Job Title
*
Incident Information
Date & Time of Incident
*
Specific Location of Incident
*
Facility Address
*
Description of Incident
*
Was Medical Attention Required?
*
Where, to who, what time, and how was the incident reported?
*
Any additional information?
*
Date Completed
*
Type your name to sign
*
Submit
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