Telehealth Services Incident Report Form
Use this form to report a telehealth service incident, describe what happened, note when it occurred, explain the impact, and request follow-up. Do not include sensitive medical details.
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Telehealth Service Type / Channel
Please Select
Video Call
Phone Call
Messaging Portal
Mobile App
Other
Incident Summary
*
People and Impact
Reporter Role or Relation
Please Select
Patient
Clinician
Support Staff
Caregiver
Other
Affected Service Area or Department
*
Affected Patient Session or Appointment
Yes
No
Unsure
Immediate Impact or Disruption
Follow-Up and Review
Current Status
*
Please Select
Open
Under Review
Resolved
Escalated
Preferred Follow-Up Contact Method
*
Please Select
Phone
Email
Portal Message
Additional Notes or Follow-Up Actions
Submit Incident Report
Should be Empty: