Incident Reporting Form

This form is to be used by Sunrise Family Healthcare staff to report the occurrence of a reportable critical incident involving our members. This form must be received within 24 hours of discovery of the incident.

Section 1: Member Information (Complete all sections)

First Name *

Last Name *

Member Address: *

City *

State *

Postal Code *

Type of Services Rendered *

Incident Report to: *

If reported, give date and time: *

If Police Report Filed, when and by whom? *

Member Phone

Section 2: Critical Incident Information (Complete all sections)

Who Reported Incident to Provider? *

Date/Time Incident Occurred: *

Location of Incident: *

Incident / Alleged Incident Type *

Please describe what happened. Be as detailed as possible and write as much as you would like. *

Section 3: Describe Corrective Action Taken to Prevent Future Incidents

Agency Action Taken *

Critical incident resolved at the time of the Report? *

Yes

No

Email Address: *

Name of Person Submitting Report: *

Title *

Phone W/Extention *