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Name of Person Involved: Address: City: Phone Number: Age: DOB: Sex: M F SS : Date of Incident: Time: am/pm Exact Location of Incident: Check Type of Accident: Check: Clerical/Data Entry Patient Communications Employee Testing Process Visitor Result reporting Volunteer Safety Other Medical Device Failure Policy/Procedural Violations Adverse Drug Reaction Vehicle Accident Needlestick Exposure to Hazardous Substance Medication Error (Wrong: Route, Dosage, Medication, Schedule) EMPLOYEE: Involved yes no Were they doing their regular job duties: yes no Observed by employee yes Hire Date: Marital Status: Situation observed only by employee yes Employee Classification: Protective Equipment being used: yes no If not used, Why: Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events, personnel involved, body part injured, reason incident occurred) (If medication error include brand name, manufacturer, dosage) (Use additional form if necessary)
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