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UNUSUAL INCIDENT REPORT LOG Month/Year: Provider/Facility: Name UI # Date & Time Injury Home Name and Address Location County: Description of the Incident Immediate Actions Taken to Ensure Health.

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While many types of incidents can happen, here are the most common types of incidents that occur in the workplace today: Positive Observations. ... Unsafe Acts. ... Near Misses. ... Minor Injuries. ... Lost Time Accidents. ... Fatalities.

The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.

Provide the basic facts. If not, start the report with a sentence clearly stating the following basic information: The time, date and location of the incident (be specific; write the exact street address, etc.). Your name and ID number. Names of other members of your organization who were present.

An MUI will fall into one of the following categories: substantiated, unsubstantiated/ insufficient evidence, or unsubstantiated/ unfounded. “Substantiated” means there is a preponderance of evidence that the alleged incident occurred.

Effective Incident Reports identify the facts and observations. They avoid inclusion of personal biases; they do not draw conclusions/predictions, or place blame. Effective Incident Reports use specific, descriptive language and identified the action(s) taken by staff as a result of the unusual incident.

The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.

Incident can refer to any event – big or small, good or bad, intentional or unintentional. A bank robbery, a funny or controversial situation, an argument between celebrities, etc. – all can be described as incidents.

Overnight relocation due to fire, natural disaster, or a mechanical failure. For example, there is a lightning strike on a home, power will be off for a week for repair, and the residents temporarily move to another house.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232