NEMT incident report template: accidents, falls, and injuries
A NEMT incident report documents any accident, fall, injury, securement problem, or disruptive event on a trip: who was involved, when and where it happened, what the driver saw, injuries, emergency response, witnesses, and who was notified. Deadlines are short. Modivcare's form asks for the report within 24 hours, MTM wants its form by the end of the next business day, and New York wants it within 2 business days.
On this page
How to use this template
The driver fills in sections 1 through 9 as soon as it is safe, on the same shift. A supervisor completes section 10 after reviewing what happened. Keep blank copies in every vehicle. Modivcare’s providers attest that drivers carry the incident form in the vehicle, and Virginia’s vehicle packet must include the broker’s accident and incident forms.
Call first, then write:
- If anyone needs medical help, call 911.
- Call dispatch right away.
- Report to the broker by phone when the broker requires it. MTM wants injuries reported verbally within three hours.
- Complete this report and send the broker’s version by its deadline.
If your broker has its own form, submit that form. This template collects the core fields the Modivcare, MTM, and New York forms ask for, so you can copy the answers across without calling the driver back. It does not replace police, insurance, or workers’ compensation forms.
Save evidence the same day. Modivcare’s form warns that an incident often becomes the basis of a lawsuit, and that losing related records, messages, photos, or video can lead to court sanctions.
The template
1. Report details
| Field | Entry | Field | Entry |
|---|---|---|---|
| Company name | Medicaid or broker provider ID | ||
| Report completed by | Date and time of report | ||
| Trip ID or broker trip number | Broker or payer | ||
| Rider name | Rider Medicaid or member ID | ||
| Rider phone | Rider age | ||
| Level of service | Leg (to appointment or return) |
2. When and where
| Field | Entry | Field | Entry |
|---|---|---|---|
| Incident date | Incident time | ||
| Address or nearest intersection | County | ||
| Location type (in vehicle, on lift, sidewalk, facility, residence) | Vehicle moving or parked | ||
| Weather and road conditions | Reported to dispatch at (time) | ||
| Pickup address | Drop-off address | ||
| Pickup on time (yes or no) | Drop-off on time (yes or no) |
3. Type of incident (check all that apply)
- Vehicle collision
- Rider fall while boarding or leaving the vehicle
- Rider fall inside the vehicle
- Wheelchair, scooter, or mobility device securement problem
- Lift or ramp problem
- Harsh braking or sudden defensive maneuver
- Medical emergency during the trip
- Rider or passenger behavior that interrupted the trip
- Driver or attendant injury
- Damage to property or a mobility device
- Allegation of abuse, harassment, or misconduct
- Vehicle breakdown that interrupted the trip
- Traffic or moving violation during a trip
- Other (describe in section 6)
4. People involved
| Name | Role (rider, escort, driver, other driver, witness) | Phone or email | Injured (yes or no) | Treatment (none, on scene, hospital) |
|---|---|---|---|---|
5. Driver and vehicle
| Field | Entry | Field | Entry |
|---|---|---|---|
| Driver name | Driver’s license number | ||
| Driver phone | Driver training and dates (PASS, other) | ||
| Shift start time | Trips completed before the incident | ||
| Vehicle make and model | License plate | ||
| VIN | Insurance company and phone | ||
| Camera in vehicle (yes or no) | Other riders on board (yes or no) | ||
| Attendant or escort on board | Service animal on board | ||
| Mobility device (describe) | Device damaged (yes or no) |
6. What happened (facts only)
Write what you saw, heard, and did, in the order it happened. Describe behavior instead of guessing at causes.
| Driver’s account |
|---|
7. Emergency response and the rider’s care
| Field | Entry | Field | Entry |
|---|---|---|---|
| 911 called (yes or no) | Police agency | ||
| Police report or MV-104A filed (yes or no) | Police report number | ||
| EMS, fire, or tow called (which) | Time emergency help arrived | ||
| Rider asked about medical treatment (yes or no) | Rider accepted or refused treatment | ||
| Rider went to (hospital, appointment, home) | Person who received the rider | ||
| That person told about the incident (yes or no) | Time the rider was handed over | ||
| Rider or representative signature (treatment decision) | Time |
8. Notifications
| Who | Name | Date and time | How (phone, email, portal) |
|---|---|---|---|
| Dispatch or supervisor | |||
| Broker or payer | |||
| Insurance company | |||
| Facility, family, or caregiver | |||
| Other |
9. Evidence kept
- Photos of the scene, the vehicle, and any damage
- Dash camera footage saved before it records over
- Trip timestamps and GPS record for the trip
- Witness names and statements
- Copy of the police report
- Dispatch messages and call records
- That day’s vehicle inspection checklist
10. Signatures and supervisor review
I certify that this report is accurate and complete to the best of my knowledge.
| Field | Entry | Field | Entry |
|---|---|---|---|
| Driver signature | Date | ||
| Supervisor name | Date reviewed | ||
| Preventable (yes or no) | Root cause | ||
| Corrective action (retraining, repair, policy change) | Date closed |
What brokers and auditors look for
Brokers look for speed, completeness, and objective facts. Deadlines differ by contract, so post your brokers’ deadlines on the office wall.
| Broker or program | What to report | Deadline |
|---|---|---|
| Modivcare | Any transportation event, with or without injury | Report form within 24 hours. Notify immediately of any accident, incident, or moving violation |
| MTM Health | Accidents and incidents | Form by the end of the business day after the event. Injuries by phone within three hours |
| New York Medicaid (Department of Health form, submitted to the transportation manager) | Every accident and incident on a Medicaid trip, plus traffic and state drug law violations during transport | Within 2 business days. Immediately for a death, an ambulance response, or a hospitalization |
| CareOregon (Oregon) | All accidents, collisions, injuries, and safety risks | Written notice immediately for injury, death, or abuse allegations against a driver. Other incidents within 24 hours |
A few more rules show up across programs:
- Objective documentation. CareOregon defines it as what was seen, heard, or can be measured. Feelings and guesses count against you.
- Police reports. CareOregon requires copies of all motor vehicle and law enforcement reports. New York wants a copy of the police report or MV-104A within 24 hours of receiving it.
- Dash cameras. CareOregon strongly recommends inward and outward facing dash cameras, and brokers can use the footage to decide whether a complaint or incident is substantiated.
- Emergencies. If an ambulance is needed, CareOregon has providers call 911, notify the broker’s dispatch immediately, and send a written report within 24 hours.
- Driving history. Federal Medicaid law requires states to make sure every NEMT provider has a process for disclosing each driver’s driving history, including traffic violations, to the state Medicaid program. New York’s incident form doubles as the way to disclose traffic violations and state drug law violations that happen during a Medicaid trip.
- Written procedures. CareOregon requires a written collision and incident investigation procedure, and it must be followed for every event.
Incident reports feed into audits. A clean file with a report, evidence, and corrective action for every event is part of passing a broker audit.
Common mistakes
- Waiting to write it up. Details fade within hours, and most deadlines are a day or two. Write it on the same shift.
- Opinions instead of facts. “The rider was drunk” is a conclusion. “The rider’s speech was slurred and they could not stand without help” is what the driver observed.
- Skipping minor events. A near-fall on the lift or a hard stop with no injury still counts under Modivcare’s rules. Minor events are also the ones that turn into claims weeks later.
- Not asking about medical treatment. Record whether the rider was offered treatment and whether they accepted or refused, with a signature.
- Losing the video. Dash cameras record over old footage on a loop. Save the clip the same day.
- No follow-up. A report without a root cause and corrective action tells an auditor nothing changed.
For securement-related incidents, retrain with the wheelchair securement checklist and keep the sign-off in the driver’s file.
Where software helps
HealthRide already holds the trip details an incident report asks for: the rider, the driver, the vehicle, scheduled and actual times, and GPS-verified miles. Dispatch can see where each vehicle is on the live map, and team chat keeps the full history of messages between drivers and dispatch. The trip log exports as a CSV or PDF for the broker’s packet.
Frequently asked questions
- What counts as a reportable incident in NEMT?
- Any event on a trip that affects safety, with or without an injury. Modivcare's form covers problems loading or unloading, falls, auto accidents, securement issues, harsh braking, rider conduct, and any defensive maneuver. New York also uses its form to disclose traffic violations and state drug law violations that happen while a Medicaid member is on board.
- How is an accident different from an incident?
- New York's Medicaid reporting rules draw the line clearly. An accident is a vehicle colliding with another vehicle, a structure, an object, a person, or an animal. An incident is an occurrence, breakdown, or public disturbance that interrupts the trip, such as a rider or driver becoming ill or unruly. Modivcare, MTM, and New York each use one form for both.
- How soon do I have to report an incident to the broker?
- It depends on the broker and the state, and your contract controls. Modivcare's incident form asks for the report within 24 hours of any transportation event. MTM wants its form by the end of the next business day and injuries reported by phone within three hours. New York wants its form within 2 business days, and immediately when the event involves a death, an ambulance response, or a hospitalization. Call dispatch and the broker first, then write the report.
- Who should fill out the incident report?
- The driver writes the account, because the driver saw what happened, and signs it. A supervisor then completes the review and follow-up section. Modivcare's form includes a driver statement section that its provider agreement requires.
- Do I need a police report for a NEMT accident?
- If police responded, get the report number and give a copy to the broker. CareOregon requires providers to give the brokerage copies of all motor vehicle and law enforcement reports. New York requires a copy of any police report or MV-104A within 24 hours of receiving it.
- How long should I keep incident reports?
- Keep them with your trip records for the longest period your contracts require. CareOregon's six-year retention rule covers accidents, injuries, and other incidents, not just trip data. New York requires six years, or three years past the rider's 18th birthday, whichever is longer. Modivcare's form also warns that you may have a duty to preserve records when an incident could lead to a lawsuit.
