Unauthorized Medical Treatment Incident Report Form
Use this form to document an incident involving medical treatment performed without authorization or proper approval.
Incident Details
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location / Facility / Department
*
Brief Incident Summary
*
People and Treatment Information
Person Involved (Name or Identifier)
*
Role of Person Involved
*
Patient
Staff Member
Visitor
Other
Type of Unauthorized Treatment
*
Authorization Attempted or Obtained?
*
Yes
No
Person Who Allegedly Authorized It (Name and Role)
Reporting and Follow-Up
Reporter Name / Role
*
Immediate Actions Taken After Discovery
*
Additional Notes or Follow-Up Required
Submit Report
Should be Empty: