Medical Incident Report Form
A Medical incident report form is usually prepared in hospitals to make an official report of an incident that has taken place inside the hospital premise. The report form provides detail information about the incident and its consequences. It also works as hospital record of incidents.
Sample Hospital Incident Report Form
General Information
Name of Hospital_____________ Owner/In-Charge of Hospital_________________
Address______________ Phone__________ Email__________ Fax_________
Report prepared by___________ Designation__________
Address_________ Phone_________ Email_________
Incident Report Information
Title of Report____________
Date of Incident___/___/____ Duration____________
Location______________
Nature of Incident_______________
Brief Description of Incident_____________________
Person/s Involved in Incident____________________
Activities of above person at the time of incident______________
Any other outside party involved in incident______________________
Contact Details______________________
Witness of Incident, Name and Contact Details______________________________
Any Injury taken place, provide details_____________________
Any Police complaint filed, provide details___________________
Does the incident created any negative impact on hospital’s public image______________________
If yes, what corrective measures have been taken____________________?
Signature_______________ Date____/____/___
Report Submitted to: Name___________ Designation____________
Signature____________ Date___/___/___
Category: Report Forms
