DCIQ: MSEICB Incident Reporting Form

MSEICB Incident Reporting Form

1. Incident details
2. - Who was affected by the incident? (Type)
    You must enter a value in this field
  - Incident date (dd/mm/yyyy)
    You must enter a value in this field
  - Incident Time (hh:mm) (hh:mm)
    Please use 24h clock format.
    You must enter a value in this field
  - Description
    Enter facts, not opinions. Do not enter the names of people as this field may be used to produce reports. Please anonymise reference to individuals, e.g. Patient A, Visitor B, Staff Member C, etc.
    You must enter a value in this field
  - Action taken at time of the Incident
    Enter action taken at the time of the incident
    You must enter a value in this field
1. RIDDOR
1. Locations
2. - Location
    Please begin typing the locations name and you will be presented with available options. For example,
    
    For a GP practice start typing the name of the GP practice or type 'GP Practice' for a full list
    
    For a Dentist start typing the name of the dental surgery or type 'Dental' for a full list
    
    For Hospitals start typing the name of the NHS Trust or Hospital name or type 'Trust' for a full list
    
    If you are unsure, select 'I don't know'
    You must enter a value in this field
  - Exact location
    You must enter a value in this field
1. ICB Directorates
2. - ICB Directorate
    Please select the ICB Directorate/sub directorate where the incident occured. (e.g. where the staff involved /reporting the incident work).
    
    Begin typing the directorate name and you will be presented with available options.
    You must enter a value in this field
1. Incident Coding
2. - Category
    For data breaches, please select Information Governance - ICB
    You must enter a value in this field
  - Sub category
    You must enter a value in this field
  - Format of Breach
    You must enter a value in this field
  - Information Asset Owner
    You must enter a value in this field
1. LFPSE
1. LFPSE - Risk
1. LFPSE - Went Well
1. LFPSE - Medications
1. LFPSE - Equipment
1. LFPSE - IT Systems & Software
1. LFPSE - Tissues & Organs
1. LFPSE - Involved Persons
1. LFPSE - Adverse Event Agent
1. LFPSE - Adverse Event Problem Buildings Infrastructure
1. LFPSE - Adverse Event Problem Estates Services
1. LFPSE - Adverse Event Problem Blood
1. LFPSE - Adverse Event Problem Blood Products
1. LFPSE - Adverse Event Safety Challenges
1. People Affected
1. Medications
1. Equipment
1. Incident Severity and Result
2. - Result
    Harm relates to either Harm/Damage/Loss caused to a person(s), property or an organisation.
    You must enter a value in this field
  - Severity
    You must enter a value in this field
1. Additional Information
  
  Please attach any relevant additional documents to the incident e.g. photos of area where accident occurred, witness statements, etc. N.B. Additional documents can be uploaded at a later date if required.
2. - Are there any documents to be attached to this record?
    You must enter a value in this field
1. Documents
1. LFPSE - Reporter
1. Details of person reporting the incident

Incidents

MSEICB Incident Reporting Form

Contact Type

Forenames

Surname

Work Email

Work Telephone Number/Extension