Occurrence / Incident Report Clinic Location of Incident Specific Location of Occurrence / Incident
Was the Occurence / Incident Witnessed ?
Clearly and concisely describe the sequence of events and include any objects, sharps, substances including brand or circumstances that contributed to the occurrence. State how the occurrence was discovered and the immediate condition of the affected person (if applicable).
Were safeguards, engineering controls or safety equipment provided by the company?
Describe Safeguards, engineering controls or safety equipment that was or was not involved or if available may have mitigated the severity of the incident etc.
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?
Describe the Injury and any Treatment Given
Was any Equipment or Medical Supply Involved?
Equipment Removed From Use
Patient Family or Caregiver Witnessed Incident?
Other Family Member / Caregiver information that may be pertainent to this review. Specific Vendor involvement in Incident.
Were there any negative impacts to patient care or outcomes?
Explain in detail
Did this incident involve an Employee?
Was the Employee Injured?
Describe the injury here:
Was a Manager or Clinic Director Notified of the Occurrence / Incident?
Approximate time of Notification In your opinion, what steps should be taken to mitigate similar incidents from occuring in the future? Submit