Negligence Evaluation Form
Please provide accurate details to help us evaluate the incident for possible negligence. Do not include sensitive identification or financial information.
Full Name of Person Reporting
*
First Name
Last Name
Contact Email
*
example@example.com
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Brief Description of the Incident
*
Type of Alleged Negligence
*
Failure to act
Improper action
Unsafe conditions
Lack of supervision
Other
Who was allegedly responsible?
*
Rate the severity of harm or potential harm caused
*
1
2
3
4
5
Contributing Factors (select all that apply)
Lack of training
Equipment failure
Policy violation
Environmental hazards
Other
To what extent do you believe negligence contributed to the incident?
*
Not at all
1
2
3
4
Entirely responsible
5
1 is Not at all, 5 is Entirely responsible
Submit Evaluation
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