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University of Pittsburgh School of Nursing
Health Incident Report Form
This form should be completed by both the student and faculty member within 24 hours after an incident
occurs; and should be submitted to the Associate Dean for Clinical Education (or designee). See Policy #302.
Today’s Date:
Date & Time of Incident:
Location of Incident:
Student’s Name:
Faculty Member’s Name:
1. Briefly describe the incident (who was involved, who was present, who was notified, what happened,
when, where).
2. Was the student or faculty member wearing gloves at the time of the incident? Yes No N/A
3. Was the student or faculty member wearing goggles, a face shield, or a face shield mask at the time of
the incident? Yes No N/A
4. List the name, address and phone number of all witnesses.
5. List any testing/treatment that was/has been provided.
6. Identify any follow-up which is planned or which was recommended.
7. How might this incident have been prevented?
Student’s signature: __________________________________________ Date ___________________
Faculty signature: ___________________________________________ Date ___________________
Date Received by:
Received in Dean’s Office: / / _______________________________
Faxed to Risk Management: / / _______________________________
Forwarded to Student Services / / _______________________________
Copy to Student File / / _______________________________
[Please use the back of this form if more space is needed.]