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.
  • 2. Exact Location of Incident

  • Date Format: MM slash DD slash YYYY
  • :
  • 3. Incident

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

  • 5. Background - Inpatient, Outpatient

  • Date Format: MM slash DD slash YYYY
  • 6. Background - Visitor, Employee, Student, Other

  • 7. Background - Treatment

    If Yes, please give the Date and Time below.
  • Date Format: MM slash DD slash YYYY
  • :
  • 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.
  • 8b. Follow-up

  • 9a.

  • 9b.

  • Date Format: MM slash DD slash YYYY