Clinic Campus Incident Form

If this is an emergency, please call 911.
Otherwise…
Please fill out the form below to report an incident on the clinic campus.
Do not include any Protected Health Information (PHI) or patient identifiers.

Name

Phone

IncidentOccurredAt

IncidentType

Location If “Other”, please describe:

Description

ImmediateActions

Witnesses

911 was called

Clinic security notified

By submitting, you confirm this report does not include Protected Health Information (PHI) or patient identifiers.