AIF1(GDS) REPORTING OF ADVERSE INCIDENTS by GENERAL DENTAL SERVICES Reported by: Name: Practitioner DS No: 1. 4. Dentist / Manager / Practice Address: 2. (please delete) 5. Contact Telephone No: 3. Date of Incident: Date Aware: Date of Report: 6. 7. 8. Patient Involved? Yes / No Age: Sex: 9. (please delete) 10. 11. Medication Incident? Yes / No 12. (please delete) (This can be medication taken by patient or administered by dentist) If Yes please give name of medication: 13. Other HSC Organisation Involved? Yes / No 14. (please delete) (e.g. Trust / GP/ Pharmacist etc) If Yes give sufficient details to allow followup e.g. location / consultant / hospital number etc 15. Brief summary of incident: (Should not contain personal detail of patient) 16. Possible Cause / Contributory Factors 17.
REPORTING OF ADVERSE INCIDENTS by GENERAL DENTAL SERVICES AIF1(GDS) Reported by: 1. Name: 2. Dentist / Manager / (please delete) 3. Contact Telephone No: 4. Practitioner DS No: 5. Practice Address: 6. Date of Incident: 7. Date Aware: 8. Date of Report: 9. Patient Involved? Yes / No (please delete) 10. Age: 11. Sex: 12. Medication Incident? Yes / No (please delete) (This can be medication taken by patient or administered by dentist) 13. If Yes please give name of medication: 14. Other HSC Organisation Involved? Yes / No (please delete) (e.g. Trust / GP/ Pharmacist etc) 15. If Yes give sufficient details to allow followup e.g. location / consultant / hospital number etc 16. Brief summary of incident: (Should not contain personal detail of patient) 17. Possible Cause / Contributory Factors
AI_Report_Form_GDS__May_2014.docx