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Get MI BCAL-4607 2007-2024

T Employee Visitor Name Resident Employee Visitor FACTS OF THE INCIDENT (ATTACH ADDITIONAL PAGES AS NEEDED): Date of Incident Time: : AM PM Name of Employee Assigned to Resident (if Applicable) Location of Incident (Kitchen, Yard, etc.) Explain What Happened / Describe Injury (if any): Action taken by Staff / Treatment Given: Corrective Measures Taken to Remedy and/or Prevent Recurrence: Name of Treating Physician / Health Care / Medical Facility / Hospital Phone.

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