Telehealth Infraction Reporting Form
Use this form to report any telehealth workflow violations or policy breaches. Do not include medical or sensitive information. All submissions are for non-HIPAA, non-sensitive incidents only.
Date of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Telehealth Platform or Service Used
*
Location (e.g., clinic, home, remote site)
*
Type of Infraction
*
Please Select
Unauthorized Access
Improper Documentation
Unapproved Communication Tool
Privacy Violation (Non-Medical)
Failure to Follow Protocol
Other
Brief Description of the Incident
*
Names or Roles of Individuals Involved (do not include sensitive details)
*
Were any supervisors or managers notified?
*
Yes
No
Actions Taken or Observed (if any)
Attach Supporting Documentation (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Reporter Name and Contact (do not include sensitive details)
*
Submit
Should be Empty: