NEMT Incident Report Form: Falls, Accidents, and Rider Complaints

An incident report protects the rider, the driver, and your contract. Brokers and states want to hear about crashes, falls, injuries, and threats fast, and they want the details in writing soon after. This form covers every kind of incident on one sheet, with the common deadlines printed at the top so the driver and dispatcher can see who to call and when.

How to use this template

1. Keep blank forms in every van. Modivcare’s yearly compliance attestation (2025 version) has drivers keep a copy of its accident and incident form in the vehicle. New York’s Medicaid transportation manual (effective August 25, 2023) requires accident procedures and forms in each vehicle’s information packet, and CareOregon’s manual lists incident reporting forms among the documents each vehicle carries.
2. Make everyone safe first. Call 911 when anyone needs emergency care. CareOregon requires the driver to call 911 when an ambulance is needed and then tell broker dispatch right away. For what to do in the moment, see a medical emergency during a ride and what to do after a NEMT vehicle accident.
3. Call the broker before you write. Use Part 1. Write your own broker’s deadlines in the third column, and the time and your initials in the last one when each call is made.
4. Fill one form per incident. If two riders were hurt in one crash, list both in Part 5 of the same form. For each person, write the role (rider, driver, attendant, escort, or other), whether they were offered care, and where they were treated.
5. Have the driver write Part 6 the same day. Memories fade. Write only what was seen, heard, or measured, as the section below explains.
6. Attach the evidence. Add the police report number, photos, saved video, and witness names.
7. Send the written report on the broker’s deadline. When the broker or the state has its own form, such as Modivcare’s report or New York’s NYSDOH NEMT Accident and Incident Report, copy the facts onto it and send that. Keep proof of when you sent it.
8. Finish Part 8. Record the drug test, the vehicle check, any retraining, and the date the broker closed the case. Then file a copy in the driver’s file and the vehicle’s file.

Log rider and facility complaints that are not safety incidents in your complaint log instead.

The template

Part 1: Who to call and by when

Event	Rule (September 2026)	Our deadline	Done
Anyone hurt, killed, missing, or in danger	Call 911 if needed. Then phone the broker right away. New York wants immediate notice of a death, an ambulance response, or a hospital stay.
Driver or staff accused of abuse, harassment, or misconduct	Call the broker right away. Call your state abuse hotline if your state law requires it.
Crash, fall, securement problem, or breakdown with no injury	Modivcare wants to hear right away. MTM Health in Rhode Island and CareOregon allow 24 hours at most.
Traffic ticket or drug law violation during a trip	Modivcare wants to hear right away about a moving violation. New York uses its state incident form for both.
Written report to the broker	24 hours at Modivcare and MTM Health in Rhode Island. CareOregon: right away when anyone is hurt, 24 hours otherwise. 48 hours in New York. 72 hours in Louisiana.
Police report copy to the broker	New York within 24 hours of receiving it. MTM Health in Rhode Island within 5 business days. The Louisiana crash report within 15 business days.
An employee dies	OSHA within 8 hours: 1-800-321-6742, unless it came from a crash on a public road outside a work zone
An employee is admitted to a hospital, has an amputation, or loses an eye	OSHA within 24 hours, with the same crash exception
Crash with injury, death, or more than $1,000 in damage	The driver’s DMV report where your state requires one: 10 days in New York (MV-104) and California (SR-1)
Your insurance company	As your policy requires
Rider’s family or facility	As the broker directs. In Louisiana, when a rider goes to an emergency room, the driver tells the state, the broker, and a family member right away.

Part 2: Report details

Field	Write the entry here in pen
Report number
Date and time of the incident
Date and time the broker was called, and the name of the person told
Broker trip or authorization number
Your Medicaid provider ID
Date and time the written report was sent, and how (portal, email, or fax)
Report completed by (name and role)

Part 3: Type of incident (check all that apply)

Check	Type
	Vehicle crash
	Hard braking or a sudden move to avoid a crash
	Rider fall or trip (at the door, boarding, in the vehicle, or at drop-off)
	Injury during a lift, ramp, transfer, or securement
	Wheelchair, scooter, or stretcher not properly secured
	Medical emergency during the ride
	Rider behavior (threats, hitting, unsafe actions)
	Allegation against the driver or staff (abuse, harassment, misconduct)
	Damage to a wheelchair, scooter, or other property
	Rider missing, dropped at the wrong place, or left without the right level of service
	Vehicle breakdown that stopped the trip
	Driver or attendant injury
	Traffic ticket or drug law violation by the driver during the trip
	Theft or a weapon found
	Other (describe)

Part 4: Where and who

Field	Write the entry here in pen
Exact location (address or nearest cross street, city, county, state)
Weather, road, and light conditions
Vehicle number, plate, and VIN
Driver’s name and license number
Time the driver’s shift began, and trips done before this one
Attendant’s name, if any
Rider names, Medicaid ID numbers, and level of service
Number of passengers on board, and whether it was a shared ride
Pickup and drop-off on time (yes or no)
Mobility devices on board (wheelchair, scooter, stretcher, walker)
Escorts, service animals, or others on board

Part 5: Injuries

Name	Role	Injury	Care offered, accepted, or refused	Treated where, and taken by

Field	Write the entry here in pen
If a rider refused care: rider’s or representative’s name, signature, date, and time

Part 6: What happened (facts only)

Field	Write the entry here in pen
What was happening just before (moving, stopped, boarding, at the door)
What happened, in order
What the driver did right after
Seat belts and securement in use at the time (yes or no, for each rider)
Where the rider went next (appointment, home, or emergency room)
Person who received the rider, and whether they were told (name, phone, time)
Photos taken (how many, by whom)
Video saved (yes or no, which camera)
Driver’s signature and date

Part 7: Police, emergency services, and other parties

Field	Write the entry here in pen
911 called (time, by whom)
Police agency and report number
Ticket issued (to whom, for what)
Ambulance or fire response (agency)
Tow needed (company, where taken)
Other driver: name, phone, plate, insurer, policy number
Witnesses: names and phone numbers

Part 8: Follow-up

Field	Write the entry here in pen
Post-accident drug and alcohol test (time done, lab, result sent to broker)
Vehicle checked by a mechanic before its next ride (date, by whom)
Driver off the schedule pending review (yes or no, dates)
Driver retraining (course and date)
Other corrective action
DMV and insurer reports filed (dates)
Copy filed in the driver’s file and the vehicle’s file (yes or no)
Broker case closed (date, outcome)
Reviewed by (owner or manager signature and date)

Reporting deadlines by broker and state

Deadlines differ by contract, so write your own broker’s times into Part 1. These are the rules with clear written deadlines as of September 2026.

Broker or state	What to report	When
Modivcare (compliance attestation, 2025)	Any accident, incident, or moving violation involving your drivers or vehicles on its trips	Tell Modivcare right away
Modivcare (incident form, version August 2022)	Any event on a trip, injury or not, including loading, a fall, a crash, a securement problem, hard braking, and rider conduct	Written report on Modivcare’s form within 24 hours
MTM Health in Rhode Island (handbook updated July 1, 2026)	Tier 1: all injuries, police or EMS response, assault, sexual misconduct, a weapon, a missing rider	Phone right away, written report within 24 hours, police report within 5 business days
MTM Health in Rhode Island	Tier 2: crashes without injury, securement problems, verbal arguments, other service disruptions	Report and written report within 24 hours
New York, every Medicaid-enrolled transportation provider (policy manual effective August 25, 2023)	Every accident or incident with a rider in or around the vehicle, including falls, fights, breakdowns, and traffic or drug law violations	NYSDOH NEMT Accident and Incident Report to the broker within 48 hours
New York	A death, an ambulance response, or a hospital stay	Report to the broker right away
New York	A police report or MV-104A about the event	Copy to the broker within 24 hours of receiving it
CareOregon (manual version 1.3, February 2024)	Any injury, death, or allegation of abuse by a driver	Written notice to the broker right away
CareOregon	Every other accident or incident on a member’s ride	Within 24 hours
CareOregon	An emergency that needs an ambulance	Call 911, tell broker dispatch right away, written report within 24 hours
Louisiana Medicaid (chapter 10, issued July 14, 2025)	Every motor vehicle accident	Report to the broker within 72 hours, with the Louisiana Uniform Motor Vehicle Accident Report within 15 business days
Louisiana Medicaid	A rider who dies or is injured in your care, whatever the cause	Written report within 72 hours
Georgia (NEMT manual, July 1, 2026)	Crashes with a driver or passenger injury or death, and moving violations on NEMT trips	The broker must tell the state right away, then send a written report and the police report. These rules must be written into every broker agreement with providers.
New Jersey mobility assistance vehicles (N.J.A.C. 8:40-3.7)	Any death or injury in the vehicle, any reportable crash, and suspected abuse or neglect	Phone the Office of Emergency Medical Services by the end of the next business day, then the written Appendix C form within 14 calendar days

CareOregon runs Oregon Health Plan rides for three coordinated care organizations, and its manual sets the standards its ride brokerages pass on to providers. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, requires you to report accidents, incidents, and injuries during a member’s ride and to cooperate with MTM’s investigation. Missing a deadline costs money. MTM Health in Rhode Island assesses $500 in liquidated damages when a provider fails any of its reporting rules, and its Virginia handbook counts a failure to report an incident or accident among its most serious violations, worth 3 points.

What the report must include

Brokers and states list the facts they need. This form asks for all of them.

Detail	Who asks for it
Date, time, and location	Modivcare; New York (county and address); Louisiana; CareOregon; Georgia (date and time); Minnesota (date and city)
Driver and vehicle	Modivcare (the VIN, plate, and insurer); New York (license and plate numbers); Louisiana; CareOregon; Minnesota (the VIN); Georgia (license and tag numbers)
Driver’s shift start and trips done that day	Modivcare
Rider names, Medicaid ID numbers, and contact details	Louisiana; Georgia; Modivcare (name, address, and phone)
Every other occupant and witness	New York (names of all occupants); Modivcare (escorts and other riders); Louisiana (names and contact details); CareOregon (all parties involved)
Each injury, and whether anyone went to a hospital	Modivcare; New York; CareOregon; Louisiana; Georgia (where each person was treated); Minnesota (number of injuries or deaths)
Whether the rider was offered care, and accepted or refused it	Modivcare
Number of passengers on board	Minnesota
Emergency services called, and tickets issued	New York (police, ambulance, fire, tow); Georgia (who was charged); Modivcare (police called and report number); Louisiana; Minnesota (whether the driver was convicted of a moving violation)
Post-accident drug test result	Louisiana (a test within 12 hours of the incident); MTM Health (post-accident testing)
Police and other government crash reports	New York; CareOregon; Louisiana; MTM Health in Rhode Island; Georgia; Minnesota (copies of every report owed to the state or an insurer)
A signed driver statement	Modivcare; CareOregon (a narrative signed by the driver)
Corrective action	Georgia; CareOregon

Minnesota’s rules apply to every Minnesota NEMT provider, since state law makes NEMT providers follow its special transportation standards (Minnesota Statutes 256B.0625, subdivision 17). Minnesota counts as an accident any crash that causes a death, an injury treated away from the scene, or damage that needs a tow (Minnesota Rules 8840.6100). It also requires a written policy on what drivers do after an accident or emergency, and a driver who fails to follow it must retake that training (Minnesota Rules 8840.5950).

How to write what happened

CareOregon asks for “objective documentation”: what was seen, heard, or can be measured, not what someone felt or sensed. Brokers use the report to decide whether the incident was preventable, so vague or emotional wording works against you.

• Write facts in time order. “At 9:42 a.m. the rider stood up while the van was stopped at the light.”
• Quote people exactly. Put what the rider or other driver said in quotation marks.
• Give measurements. Speed, distance, and times from your GPS or dash camera beat guesses.
• Leave out blame and guesses. Do not write “the rider was drunk” or “it was not our fault.” Write what you saw.
• Add a third party. CareOregon says good documentation includes an unbiased third-party account, such as a police statement or proof that the other driver’s insurer paid. A signed statement from a witness helps.
• Have the driver sign the narrative. CareOregon lists a narrative signed by the driver among the documents that support a report, and Modivcare’s form asks for the driver’s statement and signature.

If your vans have cameras, save the footage before it records over. CareOregon strongly recommends inward- and outward-facing dash cameras, and says their footage can go to the broker as evidence. Modivcare’s form warns that an incident often leads to a lawsuit and that you may have a duty to keep the emails, photos, video, and paper records about it. Losing them, even by accident, can bring court sanctions. See dash cameras in NEMT. The form holds rider health information, so store and share it the way the HIPAA rules for NEMT describe.

Crash reports to the police and the DMV

A broker report does not replace the reports the law requires of every driver. New York’s own incident policy says so: its state form does not replace any report required by federal, state, or local agencies or by your insurance policy.

• Louisiana. Drivers in an incident must notify emergency services at once under La. R.S. 32:398, and the provider sends the broker the Louisiana Uniform Motor Vehicle Accident Report within 15 business days.
• New York. The driver files form MV-104 within 10 days of any crash in the state that causes a death, an injury, or more than $1,000 in damage to one person’s property (form revised May 2025). Missing it is a misdemeanor, and DMV may suspend the license until the report is filed.
• California. The driver, or the driver’s insurance agent or legal representative, files an SR-1 with the DMV within 10 days if anyone is hurt, however slightly, or killed, or property damage is over $1,000. It is required on top of any police or insurance report.

Other states set their own crash report rules, so check your state DMV. If the crash involves another vehicle, trade license, insurance, and registration details at the scene and write them in Part 7.

When OSHA needs a call

OSHA covers your employees, not your riders. Under 29 CFR 1904.39, every employer must report:

Event	Deadline	How
An employee dies from a work-related incident	8 hours	Call the nearest OSHA area office, call 1-800-321-6742, or report online at osha.gov
An employee is admitted to a hospital, has an amputation, or loses an eye	24 hours	The same three ways

You do not report a death or injury from a motor vehicle crash on a public street or highway, unless it happened in a construction work zone. A driver hurt lifting a rider or a wheelchair at the curb is still reportable if the injury puts them in the hospital within 24 hours.

If your company had more than 10 employees at any time last year, you must also keep OSHA injury and illness records (29 CFR 1904.1). Ground passenger transportation is not on OSHA’s list of partially exempt industries. Enter each recordable injury on the OSHA 300 log and 301 form within 7 calendar days, including injuries from road crashes, and keep those records 5 years after the end of the year they cover. See OSHA rules for NEMT companies.

If your vans are commercial motor vehicles

Federal motor carrier rules cover a van used in interstate commerce that is rated at 10,001 pounds or more, or is designed or used to carry more than 8 people, driver included, for pay (49 CFR 390.5T). Those rules list an exception for “the transportation of human corpses or sick and injured persons” (49 CFR 390.3T), so ask FMCSA whether it covers your trips.

When the rules apply, you keep an accident register for 3 years after each accident, with the date, the city and state, the driver’s name, and the number of injuries and deaths, plus copies of every crash report owed to a state or an insurer (49 CFR 390.15). The federal definition of an accident, a death, an injury treated away from the scene, or a tow, leaves out incidents that happen only while riders board or leave a stopped vehicle. A rider who falls on your lift still goes on this form and to your broker.

After the report: review, retraining, and repairs

• Check the vehicle. CareOregon requires an ASE-certified mechanic to look at any vehicle damaged in an accident or other incident before it carries members again. Use the vehicle inspection checklist before its next ride.
• Retrain the driver when securement failed. Georgia removes a driver after one confirmed failure to secure a wheelchair, until the provider shows the broker proof of securement training. See wheelchair securement.
• Answer the broker on time. CareOregon expects answers to general grievances within 3 business days, or 1 business day for serious ones, and wants to know ahead of time if anything will be late.
• Expect a finding. CareOregon’s brokers decide whether each incident was preventable, and they track the results by driver and provider. Patterns can lead to a driver’s suspension or a corrective action plan for the company.
• Record it in the driver file. Minnesota requires a record of every complaint or allegation against a driver, with a summary of your investigation and the action taken. Georgia puts accident reports in both the vehicle and driver files. The driver qualification file checklist has a section for these events.

Look for patterns across reports every month. The same stop, time of day, or task behind several reports points to a fix, such as a change in your fall prevention steps or your emergency plan.

How long to keep incident reports

Rule	How long
MTM Health’s standard agreement (full records of your operations)	10 years
New York (the NEMT Accident and Incident Report and everything attached)	At least 6 years, or 3 years past the rider’s 18th birthday, whichever is longer
CareOregon (records of NEMT services, including accidents, injuries, and incidents)	At least 6 years
New Jersey N.J.A.C. 8:40-3.9 (required records other than patient medical records)	At least 5 years
OSHA 300 log and 301 forms (29 CFR 1904.33)	5 years after the end of the year they cover
Minnesota Rules 8840.6100 (accident records)	At least 3 years
FMCSA accident register (49 CFR 390.15)	3 years after each accident

The longest rule that applies to you wins. Claims can come long after a crash, so check with your insurer before you destroy any report. For all your records in one schedule, see NEMT record retention.