Nursing & Health Sciences

Incident Report

Download this form as a PDF

Note: An agency incident report must also be completed.

 

NAME OF STUDENT: ________________________________        DATE: ____________________

COURSE: _________________________________________________________

LOCATION OF INCIDENT: ____________________________________________

To be completed by student:

1. Describe in detail what occurred. Give specific times wherever possible.

 

 

 

2. What action was taken by you or others after this event occurred and who was notified. Give specific times wherever possible.

 

 

 

3. What negative effect (if any) did this occurrence have on the patient? What assessment findings validate your conclusion?

 

 

 

4. What suggestions do you have to either prevent this from occurring again or for alternative ways to handle a similar situation?

 

 

 

Student Signature__________________________________ Date_____________________

 

To be completed by instructor and/or chairperson:

5. What needs to be done to correct this error?

 

 

6. Remedial action carried through. Cite dates when remediation will be complete and any further action taken.

 

 

Instructor__________________________________________

 

Date__________________________________________  

 

__________________________________________

Nursing & Health Sciences Chair

cc: Program Director/Coordinator

Assistant to the Chair (Assessment Director/Coordinator)

Student file

 

Revised 12/06