NALRRG Incident Form

Welcome National Assisted Living Risk Retention Group members!

The Littleton Group is responsible for gathering and maintaining information on all incidents that occur at your facility, for purposes of trending and tracking causes of potential risk to you. This information is vital to the NALRRG, regardless of whether the incident is reportable or not.

Therefore, you should report the following to The Littleton Group as soon as possible:

Please complete and submit the following information regarding your incident. Your assignment will be forwarded to our Captive Healthcare Team.

Please contact us with any questions or comments.

NOTE: Fields marked with an asterisk (*) are required.

Insured Information
Facility:*
Contact First Name:*
Contact Last Name:*
Contact E-Mail:*
Facility Address:*
Facility Address (cont):
City:*
State/Province:*
Zip Code:*
Phone Number:*
Resident/Visitor Information
First Name:*
Last Name:*
Gender:
Address:
Address (cont):
City:
State/Province:
Zip/Postal Code:
Medicare/Medicaid/Self-Pay:

Incident Information
Date of Incident:* (MM/DD/YYYY)
Incident Location:
Shift:
Injury:
Body Part Injured (Please Be Specific):
Treatment:
How Incident Occurred:
 
Upload Supporting Documents
(DOC or PDF only please):
File size must be less than 5MB.
 
Upon submission, you will receive an email confirmation for your records.
 
* I acknowledge the form is completed.