Free Nursing Home Incident Affidavit Template
Nursing Home Incident Affidavit
I, [Your Name], being of legal age, sound mind, and under penalty of perjury, do hereby declare:
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I am a [resident/staff member/witness] at [Your Company Name], located at [Your Company Address]. I have personal knowledge of the facts stated in this Affidavit.
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On [Month Day, Year], at [HH:MM AM/PM], in [Incident Location] of [Your Company Name], I observed an incident involving [Party A's Name], a [resident/staff member] of the nursing home, and a [resident/staff member] named [Party B's Name]. [Party A's Name] was attempting to navigate his wheelchair through a doorway when his chair became stuck. [Party B's Name] attempted to assist him, but in the process, [Party A's Name] was accidentally tipped from his chair.
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As a result of the incident, [Party A's Name] sustained a minor bruise on his left arm and appeared to be shaken. His wheelchair was not damaged, and no other property damage was observed.
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The incident was immediately reported to the nursing home management. An incident report was filed, and [Party A's Name] received medical attention for his bruise.
I affirm that the information provided in this Affidavit is true and correct to the best of my knowledge and belief. I understand that if I have provided false information in this Affidavit, I may be subject to penalties for perjury.
[Your Name]
Sworn to and subscribed before me this [Month Day, Year]
[Name of Notary Public]
Notary Public, State of [State Name]
