NEMT Passenger Fall Incident Report

Documents a passenger fall during boarding, transport, or alighting, including injuries, witnesses, immediate response, and corrective action. Supports liability defense, audit trail, and follow-up review.

Submission Notice

• What happens after I submit?
• Reporter name
  Enter the name of the person completing the report.
• Reporter role
• Reporter contact number
  Optional. Use only if follow-up contact is needed.

Incident Details

• Date of incident
• Time of incident
• When did the fall occur?
• Location of incident
  Enter the address, facility name, or vehicle location where the fall occurred.
• Vehicle or unit number
  Optional. Include only if relevant to internal tracking.
• Route or trip ID
  Optional. Use the trip reference if available.
• Describe what happened
  Provide a factual description of the fall, including surface conditions, assistive devices, steps, curb height, vehicle movement, or other observable factors.

Passenger Information

• Passenger name
  Optional unless your organization requires identification for follow-up.
• Passenger identifier
  Optional. Use a member ID, trip ID, or other internal identifier instead of collecting unnecessary PII.
• Was the passenger using assistance?
• Did the passenger decline to provide details?

Injury and Medical Response

• Did the passenger report or show an injury?
• Describe the injury
  Use minimum necessary detail. Include body part affected, visible bleeding, pain, or mobility impact if known.
• Was medical attention requested or provided?
• Medical response
• Was an emergency contact notified?

Witnesses and Immediate Response

• Were there witnesses?
• Witness details
• Immediate actions taken
• Observed scene conditions

Corrective Action and Review

• Is corrective action needed?
• Corrective action details
  Describe training, equipment inspection, route review, maintenance, or other preventive steps.
• Supervisor review required
• Attach supporting files
  Optional. Upload photos, statements, or related documentation if available.