HTML Preview Dental Office Incident Report page number 1.
Reported by: _________________________________ Date of Incident: ____________________ Date: ____________________
Dental Office: ____________________________________ Name of Supervising Dentist (print): __________________________
Office Address: _________________________________________________________________________________________
City: ___________________________________________ Prov: ______________________ P.C.:_________________________
Type of Incident: __________________________________________________________________________________________
Witnessed: Yes ______ No ______ By: ______________________________ Title: _____________________________
NAME OF CLIENT AND/OR OTHERS INVOLVED: ______________________________________________________________
CLASSIFICATION: Verbal Abuse: ________ Physical Abuse: ________ Treatment Error: ________ Injury: ________
Equipment Error: ________ Unsafe Working Environment: ________ Sharp Injury: ________
Other (specify) ______________________________________________________________________
TYPE OF INCIDENT: (attach additional sheets as required)
Was the dentist notified: Yes_____ No _____ Did the dentist examine the patient post incident: Yes ____ No ____
(Describe briefly what happened: (attach additional sheets as required)
Type of Injury: ____________________________________________________________________________________________
________________________________________________________________________________________________________
Suggested Treatment: _____________________________________________________________________________________
_______________________________________________________________________________________________________
Other Recommendations: __________________________________________________________________________________
________________________________________________________________________________________________________
(Signature of Person Reporting Incident) (Signature of Office Manager/Receptionist)
Dental Office Incident Report
An Incident Report Should Be Filed Within 48 Hours