Incident Reporting System
Administrator
A. Reporter Information
Staff Full Name
Staff ID
Staff Designation
Department / Unit
Contact Number
B. Incident Information
Incident Date (dd/mm/yy)
Incident Time (24hrs)
Incident Location
Type of Incident
Select
Near Miss
Actual
Category of Incident
Select
Clinical
Non-Clinical
Sentinel Events
Occupational Safety & Health
Type of Person Involved
Select
Inpatient
Outpatient
Daycare patient
Others
Was Patient Involved?
Select
Yes
No
Brief Description of Incident
Character count: 0
C. Patient Information
Patient Name
Patient MRN
Patient Age
Patient Gender
Select
Male
Female
Not recorded
Patient Race
Select
Malay
Chinese
Indian
Others
Primary Consultant
Harm Level
Select
None
Minor
Moderate
Severe
Death
Patient Diagnosis
Date of Admission
Room Number
Submit Report
