* 1. Date of incident?

* 2. What was the call # of the case in question?

* 3. What was your role in this case?

* 4. How were you involved in this event?

* 5. Category of event

* 6. Type of event (choose the option that best describes the event)

* 7. Event Result

* 8. Please describe the event in the space provided

* 9. Provide your opinion as to the cause of the patient hazard event

* 10. Please provide any suggestions that would prevent another similar event

* 11. Was the failure or malfunction of a device or piece of equipment integral to or causative of the event?

* 12. Type of device or piece of equipment?

* 13. Manufacturer

* 14. Model number

* 15. Approximate age of device or piece of equipment

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