Mobility Assistance Incident Report Form
Use this form to report and document incidents involving mobility assistance, equipment, assistance delays, transfers, or related safety concerns.
Incident Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Role or Relationship to the Incident
*
Please Select
Staff Member
Caregiver
Supervisor
Witness
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Organization or Location
Incident Details
Incident date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident time
*
Hour Minutes
AM
PM
AM/PM Option
Exact location of incident
*
Incident type
*
Fall during transfer
Equipment malfunction
Improper assistance
Delayed assistance
Slip/trip related to mobility aid
Other
Incident summary/description
*
Person Requiring Mobility Assistance
Full Name or Identifier
*
Age or Age Range
Mobility Aid or Device Involved
*
Please Select
Wheelchair
Walker
Cane
Crutches
Transfer Board
Lift
Escort Assistance
Other
Assisted by Staff at the Time
*
Yes
No
Incident Circumstances and Contributing Factors
What was the person doing immediately before the incident?
*
Please Select
Walking
Standing
Transferring
Using stairs or ramp
Sitting
Being assisted by staff
Other
Environmental conditions
*
Wet floor
Poor lighting
Crowded area
Uneven surface
Obstruction
None
Other
Contributing factors
*
Equipment issue
Insufficient staffing
Communication issue
Fatigue
User error
Unknown
Other
Was the mobility equipment being used correctly?
*
Yes
No
Unsure
Injury, Impact, and Immediate Response
Did any injury occur?
*
Yes
No
Injury type or affected area
Please Select
Head
Neck
Back
Shoulder
Arm
Hand
Hip
Leg
Foot
Other
Visible symptoms or signs
Pain
Swelling
Bruising
Redness
Bleeding
Limited movement
Dizziness
Distress
Other
Immediate actions taken
Assisted to seat
First aid provided
Supervisor notified
Medical evaluation requested
Emergency services called
Equipment removed from use
Other
Did the incident interrupt the planned mobility support?
*
Yes
No
Witnesses and Follow-Up Actions
Witness Name and Contact Information
Who was notified?
*
Supervisor
Family/Caregiver
Nurse/Medical Staff
Maintenance
Safety Team
Other
Recommended follow-up actions
Additional review or corrective action needed?
*
Yes
No
Submit Report
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