Healthcare Adverse Event Incident Report
Please complete this form to report any adverse event or incident that occurred in the healthcare setting. Accurate reporting helps improve patient safety and care quality.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., department, room number)
*
Type of Adverse Event
*
Please Select
Medication Error
Fall
Equipment Failure
Procedure Complication
Infection
Other
Describe the Incident in Detail
*
Who was involved in the incident? (Select all that apply)
*
Patient
Visitor
Healthcare Staff
Other
Name(s) of Person(s) Involved (if known)
Were there any witnesses?
*
Yes
No
Witness Name(s) and Contact Information (if applicable)
Immediate Actions Taken
*
Outcome or Harm (if any)
*
Please Select
No Harm
Minor Injury
Major Injury
Death
Other
Reporter Full Name
*
First Name
Last Name
Reporter Role/Position
*
Please Select
Nurse
Physician
Technician
Administrator
Other
Reporter Contact Email
*
example@example.com
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
Should be Empty: