This form is for Health and Wellness Services staff only. Use this form to report an incident or near miss event including injuries, unexpected outcomes, breach in procedure, privacy incident or ...

Submit one claim form per incident and attach an itemized list if necessary ... The State is not automatically responsible for bills (medical, repairs or other) simply because the incident occurs on ...

If you have an injury requiring medical treatment that would cause a bill to be generated, you must complete an incident report below before any bills will be paid, as well as an OJI Benefits ...