Note: This is a confidential form used only for quality improvement purposes. Submit the completed form to the Department Head of the School of Nursing. Who was involved? Patient (DO NOT include patient name or any identifiers on this form) ⁭ (Check All that Student (If the incident involves injury to a student on University property, ⁭ Apply) immediately notify the University Police) University Faculty/Staff (If the incident involves injury to a faculty/staff while ⁭ working, also complete Human Resources Office Form #118) Other(specify): ______________________________________________________ ⁭ Name of Student/Faculty/Staff: _________________________ W#________________ Name of Supervising Faculty (if applicable): _________________________________ Time and Place of the Place/department where incident occurred: ________________________________ Incident Date:_____________ Time:________________ The Incident State fully what happened, clearly, concisely, mentioning all factors of the incident. Action Taken If incident involved a patient, was the patient’s physician notified? Yes No ⁭ ⁭ Was the patient/family aware of the incident or notified of incident? Yes No ⁭ ⁭ If incident was caused by student misjudgment, was a Clinical Misjudgment Form completed? Yes No ⁭ ⁭ If incident resulted in student injury on University property, was the University Police notified? Yes No ⁭ ⁭ If incident resulted in faculty/staff injury while working, was Human Resources Office Form #118 completed? Yes No ⁭ ⁭ Summarize action taken, such as treatments, new orders given, etc: Additional comments/information (if needed) Follow-Up Resolution: Appendix B SOUTHEASTERN LOUISIANA UNIVERSITY School of Nursing LEARNING EXPERIEINCE AGREEMENT Intradermal, Subcutaneous and Intramuscular Injections
Note: This is a confidential form used only for quality improvement purposes. Submit the completed form to the Department Head of the School of Nursing. Who was involved? (Check All that Apply) ⁭ Patient (DO NOT include patient name or any identifiers on this form) ⁭ Student (If the incident involves injury to a student on University property, immediately notify the University Police) ⁭ University Faculty/Staff (If the incident involves injury to a faculty/staff while working, also complete Human Resources Office Form #118) ⁭ Other(specify): ______________________________________________________ Name of Student/Faculty/Staff: _________________________ W#________________ Name of Supervising Faculty (if applicable): _________________________________ Time and Place of the Incident Place/department where incident occurred: ________________________________ Date:_____________ Time:________________ The Incident State fully what happened, clearly, concisely, mentioning all factors of the incident. Action Taken If incident involved a patient, was the patient’s physician notified? ⁭ Yes ⁭ No Was the patient/family aware of the incident or notified of incident? ⁭ Yes ⁭ No If incident was caused by student misjudgment, was a Clinical Misjudgment Form completed? ⁭ Yes ⁭ No If incident resulted in student injury on University property, was the University Police notified? ⁭ Yes ⁭ No If incident resulted in faculty/staff injury while working, was Human Resources Office Form #118 completed? ⁭ Yes ⁭ No Summarize action taken, such as treatments, new orders given, etc: Additional comments/information (if needed) Follow-Up Resolution: Appendix B SOUTHEASTERN LOUISIANA UNIVERSITY School of Nursing LEARNING EXPERIEINCE AGREEMENT Intradermal, Subcutaneous and Intramuscular Injections
ug_stud_hb_3_18_15.docx