Nursing Home Incident Affidavit
I, [Your Name], being of legal age, sound mind, and under penalty of perjury, do hereby declare:
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.
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.
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.
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]
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