Hospital And Ambulatory Surgical Center Fax Report Form Page 7
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RACE:
HISPANIC INDICATOR
___Asian
__Patient is Hispanic/Latino/Spanish
___Black/African American
__Patient is not Hispanic/Latino/Spanish
___ White
___ American Indian/Alaska Native
___ Native Hawaiian or Other Pacific Islander
___ Unknown/Not Specified
___ Other Race (specify) _____________________
ETHNICITY: Please check all that apply:
___Cuban
___ Asian Indian
___ Honduran
___Dominican
___ Brazilian
___ Japanese
___ Mexican/Mexican American/Chicano
___ Cambodian
___ Korean
___ Puerto Rican
___ Cape Verdean
___ Laotian
___ Salvadoran
___ Caribbean Island
___ Middle Eastern
___ Central American (not specific)
___ Chinese
___ Portuguese
___ South American (not specific)
___Columbian
___ Russian
___ African
___ European
___Eastern European
___ African American
___ Filipino
___ Vietnamese
___ American
___ Guatemalan
___ Other Ethnicity
___ Asian
___ Haitian
___ Unknown/Not Specified
DPH Incident/Allegation Type (See table #4):__________________________________________________
Type(s) of Harm (See table #5): _____________________________________________________________
Body Part(s) Affected: ____________________________________ L:_____ R: _____
Patient’s activity at time of occurrence (See table #6): __________________________________
_____________________________________________________________________________
Place of Occurrence:
___________________________________________________________________
What equipment, if any, was being used at time of occurrence? __________________________
______________________________________________________________________________
NARRATIVE QUESTIONS:
Please ATTACH narrative answers to the following questions on a SEPARATE page(s).
1. Were there any safety precautions in place? Yes________ No_________
If yes, describe what precautions were in place:
2. NARRATIVE:
(Please address the following: What happened? What factors contributed to the occurrence? Any relevant information
which establishes cause? Have there been similar incidents in the past? How were the injuries treated?)
3. Were there any unusual circumstances involved? Yes________ No__________ If yes, please describe.
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