Da Form 4106 - Incident Report
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2INCIDENT REPORT
For use of this form, see AR 40-68; the proponent agency is OTSG.
Privacy Act of 1974, 5 USC 552a governs access to this document.
Quality Management Document under 10 USC 1102. Copies of this document, enclosures thereto, and information therefrom will not be further released
under penalty of the law. Unauthorized disclosure carries a statutory penalty of up to $3,000 in the case of a first offense and up to $20,000 in the case of
a subsequent offense. In addition to these statutory penalties, unauthorized disclosure may lead to adverse actions under the UCMJ and/or adverse
administrative action, including separation from military or civilian service.
Instructions: See page 2 for instructions in completing this form and definitions of terms marked with an asterisk (*).
DATE OF EVENT
TIME OF EVENT
1.
(YYYYMMDD)
2.
(Military time.)
3. LOCATION OF EVENT
This incident was a/an:
4.
Actual Event/Incident*
Near Miss/CloseCall*
(Check one)
5. This incident involved harm or the potential for harm to a patient.
Yes
No
This incident involved the following individuals:
6.
(Check all that apply)
Patient
Family Member
(
Adult
)
Staff Member
Visitor
Volunteer
Other
Child < 18 years old
Type of Event.
7.
(Check all that apply) NOTE: Items marked with ** require additional action; see reverse for further detail.
Fall
Property Damaged/Destroyed
Adverse Drug Reaction**
AMA/Left Without Being Seen**
Infant Abduction
Property Lost/Stolen
Assault
(e.g., physical, verbal, emotional)
Infant Discharge to Wrong Family
Radiology Related
Blood Products Related**
Laboratory Related
Rape
Delay in: Diagnosis/Treatment/Transfer
Medication Related
Restrained Patient Injury
Equipment/Supply Problem**
Needle Stick/Sharp Injury
Suicide in a 24-hour Facility
Other
Exposure to Blood/Body Fluids
Obstetrics Related
(Specify)
Facility/Physical Plant Problem
Operative/Invasive Procedure Related
Effect of this Incident on the Individual(s) Involved.
8.
(Explain in Block 11.)
No harm*sustained
Harm sustained
9. Witness(es) who may be able provide additional detail concerning this incident.
a. Name
b. Telephone Number
10. Department(s) Involved in this Incident.
(Check all that apply)
Ambulatory Care
Information Management
Nursing
Radiology
Behavioral/Mental Health
Laboratory
OB/GYN
Surgery
Logistics
Other
Dental
Pediatrics
(Maintenance, Grounds, Housekeeping)
(Specify)
Emergency Care
Medicine
Pharmacy
11. Description of Incident.
(Provide concise, factual, objective details.)
(If more space is needed, use reverse or attach an additional page.)
12. What actions, if any, could have been taken to prevent this incident from occurring?
13. Patient ID Plate or Printed Name and SSN,
13. Patient ID Plate or Printed Name and SSN,
14. Name, Grade, Title of Individual Completing Form
Address, and Daytime Telephone Number
16. Date of Report
15.Signature
(YYYYMMDD)
FOR ADMINISTRATIVE USE ONLY.
Incident Log Number
SAC score
Is additional event analysis required?
YES
NO
Page 1 of 2
PREVIOUS EDITIONS ARE OBSOLETE
DA FORM 4106, FEB 2004
APD LC v1.01ES
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