PATIENT'S AGE

Question Title

* 1. PATIENT'S AGE

PATIENT'S GENDER

Question Title

* 2. PATIENT'S GENDER

PATIENT'S IMMIGRATION STATUS

Question Title

* 3. PATIENT'S IMMIGRATION STATUS

CONDITION MOST RESPONSIBLE FOR ADVERSE OUTCOME (e.g. diabetes, PTSD, coronary artery disease, pregnancy)

Question Title

* 4. CONDITION MOST RESPONSIBLE FOR ADVERSE OUTCOME (e.g. diabetes, PTSD, coronary artery disease, pregnancy)

ADVERSE OUTCOME CLASSIFICATION (check all that apply)

Question Title

* 5. ADVERSE OUTCOME CLASSIFICATION (check all that apply)

DESCRIBE ADVERSE OUTCOME AND SEVERITY OR IMPACT (e.g. stroke, right-sided weakness). For deaths, include cause of death if known.

Question Title

* 6. DESCRIBE ADVERSE OUTCOME AND SEVERITY OR IMPACT (e.g. stroke, right-sided weakness). For deaths, include cause of death if known.

In your opinion, COULD THIS ADVERSE OUTCOME HAVE BEEN PREVENTED?

Question Title

* 7. In your opinion, COULD THIS ADVERSE OUTCOME HAVE BEEN PREVENTED?

NARRATIVE DESCRIPTION OF ADVERSE OUTCOME and explanation of how it could have (or why it could not have) been prevented by better access to healthcare. Do not include any information that could be used to identify an individual patient.

Question Title

* 8. NARRATIVE DESCRIPTION OF ADVERSE OUTCOME and explanation of how it could have (or why it could not have) been prevented by better access to healthcare. Do not include any information that could be used to identify an individual patient.

YOUR NAME, QUALIFICATIONS, AND CONTACT INFORMATION (email, phone, fax, and mailing address).This information may be used to verify the accuracy of information on this form or to obtain additional information about the adverse outcome but it will not be used for any other purpose. Please indicate if you, the patient or a representative of the patient are willing to provide additional information. Do not include any information that could be used to identify an individual patient.

Question Title

* 9. YOUR NAME, QUALIFICATIONS, AND CONTACT INFORMATION (email, phone, fax, and mailing address).This information may be used to verify the accuracy of information on this form or to obtain additional information about the adverse outcome but it will not be used for any other purpose. Please indicate if you, the patient or a representative of the patient are willing to provide additional information. Do not include any information that could be used to identify an individual patient.

T