Form Testing

Reportable Event Form

This report and the information contained therein is a privileged communication to the Office of Corporate Compliance and is protected under the Attorney/Client privilege. The Office of Corporate Compliance has authorized the Risk Management Specialist to collect and investigate incidents reported therein. (If you have any questions, call 327-6444).

1.

Please complete this report (in its entirety) in the event of an accident, discovery of a hazardous condition, or any occurrence which is not consistent with routine operation of the institution or routine care of a patient. Submit all forms to Risk Management, Lyttle Hall, 3rd Floor, Room 317, in the Office of Corporate Compliance.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone - Home

Phone - Work

Age

Sex

2. Exact Location of Incident

Building/Department

Floor

Room Number

Date

Time

: HH

MM

Discovered by

Title

3. Incident

Incident Type

Concise Description

Concise description of occurrence (state significant facts in chronological order, i.e., include specific entrance/exit or condition surrounding incident)

4. Witnesses

Name

First Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

5. Background - Inpatient, Outpatient

Inpatient
Outpatient

Patient's Diagnosis

Admission Date

Surgical Procedure/Outpatient Treatment

Medication Within Past 8 Hours

Yes
No

Name of Medication

Medication Type

Sedative
Duretic
Laxative
Other

6. Background - Visitor, Employee, Student, Other

Visitor
Employee
Student
Other

Reason for being at facility

Department

Title

On Duty

Yes
No

7. Background - Treatment

Was there an injury?

Yes
No

Patient/Family aware of incident?

Yes
No

Was examination or treatment refused?

Yes
No

Injured person's signature, if Yes.

Attending physician notified?

Yes
No

If Yes, please give the Date and Time below.

Date

Time

: HH

MM

X-ray ordered

Yes
No

Results (if known)

Diagnosis and Recommendation

Signature of MD

8a. Reporting

EMPLOYEE must report incident to supervisor. STUDENT must report incident to the Dean of Student Affairs. VISITOR must call the Department of Public Safety at 327-6666.

Reportable Event Form

1.

2. Exact Location of Incident

3. Incident

4. Witnesses

5. Background - Inpatient, Outpatient

6. Background - Visitor, Employee, Student, Other

7. Background - Treatment

8a. Reporting

8b. Follow-up

9a.

9b.