Incident Report

Safety

Report workplace incidents, injuries, or safety concerns. Submit immediately after any incident occurs.

(513) 587-4923 referrals@bridgecareohio.com

Important: For life-threatening emergencies, call 911 first. Then notify your supervisor at (513) 587-4923 and complete this report as soon as possible.

1Reporter Information

Employee Name*

Phone Number

Email Address

2Incident Details

Date of Incident*

Time of Incident

Location of Incident*

Client Name (if applicable)

Type of Incident*

Severity

3Description & Response

Detailed Description of Incident*

Immediate Action Taken

Witnesses (Names and Contact Info)

Was a Police Report Filed?

4Signature

I certify that the information provided is accurate and complete to the best of my knowledge.

Electronic Signature (Type Full Name)*

Date*

Your submission will be sent securely to our team at referrals@bridgecareohio.com. A completed PDF copy will be available for download after submission.

Incident Report | BridgeCare Employee Portal

Incident Report

1Reporter Information

2Incident Details

3Description & Response

4Signature