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This online form has been provided for employees of Cowboy Clinic & Urgent Care to submit in accordance with company policy related to any occurrence or incident that falls outside the normal operation of daily business which may or may not involve the function of the provision of care.  Please complete the form below and submit.

Occurrence / Incident Reporting

Occurrence / Incident Report
Was the Occurence / Incident Witnessed ?
Were safeguards, engineering controls or safety equipment provided by the company?
Was this Incident a "Sharps Injury" or an Exposure to Blood Borne Pathogens?
Was the injury suffered by an employee?
Was the Provider on Duty Notified?
Was there and Injury Observed and/or Reported?
Was any Equipment or Medical Supply Involved?
Equipment Removed From Use
Was a Patient Involved?
Patient Family or Caregiver Witnessed Incident?
Was a Vendor Involved?
Were there any negative impacts to patient care or outcomes?
Did this incident involve an Employee?
Was the Employee Injured?
Was a Manager or Clinic Director Notified of the Occurrence / Incident?

Thanks for submitting!

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