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Run: NEMT Passenger Fall Incident Report

Use this NEMT Passenger Fall Incident Report to document a fall during boarding, transport, or alighting, capture witness and response details, and create a ...

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Submission Notice

What happens after I submit?

Reporter name (required)

Enter the name of the person completing the report.

Reporter role (required)

Reporter contact number

Optional. Use only if follow-up contact is needed.

Incident Details

Date of incident (required)

Time of incident (required)

When did the fall occur? (required)

Location of incident (required)

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 (required)

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?

Yes No N/A

Injury and Medical Response

Did the passenger report or show an injury? (required)

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? (required)

Medical response

Was an emergency contact notified?

Witnesses and Immediate Response

Were there witnesses? (required)

Witness details

Immediate actions taken (required)

Observed scene conditions

Corrective Action and Review

Is corrective action needed? (required)

Corrective action details

Describe training, equipment inspection, route review, maintenance, or other preventive steps.

Supervisor review required

Yes No N/A

Attach supporting files

Optional. Upload photos, statements, or related documentation if available.

Get your results

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Email (required)

Your name (optional)

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