Submit Allied 24/7 Employee Incident Report
Employee Name:*
Title:*
Select Title
Bone Densitometry Tech
Breast Sonography Tech
Cardiac IR Tech
Cardiovascular IR Tech
Computed Tomography Tech
Echo Cardiography Tech
Interventional Radiology Tech
Mammography Tech
MRI Tech
Nuclear Medicine Tech
Radiation Therapist
Radiography Tech
Registered Radiologist Assistant
Respiratory Therapy
Sonography Tech
Surgical Tech
Surgical Tech - CVOR
Surgical Tech - OR
Ultrasound Tech
Vascular IR Tech
Vascular Sonography Tech
X Ray Tech
Facility Involved:*
Date of Incident:*
Time:
Type of Incident:*
Employee Injury
Disciplinary
Policy Violation
other
If Other, specify:
What Occured:*
Resolution*
No Follow up needed
Reported to CNO
Follow up need by
If follow up need by someone, specify:
Resolution Notes*
Additional Comments