Date of incident?

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* 1. Date of incident?

What was the call # of the case in question?

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

What was your role in this case?

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* 3. What was your role in this case?

How were you involved in this event?

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* 4. How were you involved in this event?

Category of event

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* 5. Category of event

Type of event (choose the option that best describes the event)

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

Event Result

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* 7. Event Result

Please describe the event in the space provided

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* 8. Please describe the event in the space provided

Provide your opinion as to the cause of the patient hazard event

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

Please provide any suggestions that would prevent another similar event

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

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

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

Type of device or piece of equipment?

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* 12. Type of device or piece of equipment?

Manufacturer

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* 13. Manufacturer

Model number

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* 14. Model number

Approximate age of device or piece of equipment

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* 15. Approximate age of device or piece of equipment

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