Health Information Management Ethics Incident Report Form
Use this form to report ethics-related incidents in health information management. Please provide as much detail as possible to assist with the review and resolution process.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Please describe what happened during the incident.
*
Who was involved in the incident? (List names, roles, or departments if known; do not include sensitive personal data.)
How was the incident discovered?
*
Please Select
Self-disclosed
Witnessed by staff
Reported by another person
Routine audit or review
Other
Was any immediate action taken?
*
Yes, corrective action was taken
Yes, incident was reported to supervisor
No immediate action was taken
Other
What follow-up or resolution are you requesting?
*
Please Select
Investigation and feedback
Training or education
Formal disciplinary review
No follow-up needed
Other
Additional comments or information (optional)
Submit Incident Report
Should be Empty: