Critical Incident Reporting

Please enter dates in DD/MM/YYYY format

NB: The incident number only allows alpha numberic characters

SECURE Critical Incident Reporting Form - the results will be sent directly to Sue Barter

Please fill in the form to submit the details of the incident:

This form should be completed whenever an actual or potential adverse incident occurs, including those  which involve ionising radiation

Date:

Incident Number:

Location:

Details of Staff/Patients involved:

Details of equipment involved:
(if radiation incident - exposure factors)

DETAILS OF INCIDENT
(If a radiation incident, include overleaf a diagram of the positions of individuals and equipment)

Person completing form and designation: (Optional)

 

Reported to:  

Date:

Investigation and Follow Up

Result of investigation:
Action taken:
Estimate of likelihood of this happening again:
Name of investigator (optional):