Incident Report Form - Chesapeake Medical Staffing printable pdf download

2401 York Road

Timonium, MD 21093

Incident / Injury Report Form

Phone (410) 321.4267

Fax (410) 321.4980

*If you are reporting an on the job injury and have not yet spoken with a Medcor Nurse,

Please STOP and call them NOW at 1-800-775-5866.

Complete and return this form after you have spoken to a Medcor Nurse*

This incident report must be completed and sent to the CMS office as soon as possible following

the injury.

Fax to 410-321-4980 or email to .

If you are unable to complete this form yourself, please ask your clinical supervisor to assist you, or

call our office at 410-321-4267 and someone can assist you with completing the form.

If applicable for employee injury, once your incident/injury report has been reported to our Worker’s

Compensation Administrator, you will be assigned a claim number. We will provide you with this

number in case you need it for any treatment purposes.

Chesapeake Medical Staffing’s preferred provider is Concentra. Treatment provided by Concentra

will automatically be sent to our Worker’s Compensation Administrator for direct payment. If you

receive treatment somewhere other than Concentra, please forward any bills or invoices you receive due

to the incident/injury to the CMS benefits department via email at . The actual

invoice may be necessary for reimbursement from our insurance company, so please keep all original

bills and receipts. Please note: you must be evaluated by Concentra if you are treated somewhere else,

unless your work assignment location is more than 50 miles from a Concentra facility.

Printed Employee Name: ________________________________ Certification ________________

Are you reporting an incident

or on-the-job injury

Date of incident/injury: ________________________

Time of incident/injury: _________________

Did this incident / injury occur in a facility

client’s home

or in the CMS office

Name of Facility / Client where incident / injury occurred: ____________________________________

Address of Facility / Client where incident / injury occurred: __________________________________

____________________________________________________________________________________

If the incident /injury occurred in a facility, on which unit did the incident/injury occur:___________

 Describe the incident/injury in detail: (including events that occurred immediately before)

_______________________________________________________________________________

 Describe the cause of the incident/injury, including any environmental factors that may have lead

to the incident/injury: _________________________________________________________

Incident Report Form - Chesapeake Medical Staffing