Dd Form 2852 - Patient Movement Event/near Miss Report Page 2

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SECTION III - MISSION INFORMATION
8. MISSION ID
9. AIRCRAFT TYPE/
10. EN-PLANE
11. DE-PLANE
12. ORIGINATING
13. DESTINATION
14. CCATT
ONBD?
NUMBER
TAIL NUMBER
ICAO
ICAO
FACILITY
FACILITY
YES
NO
SECTION IV - PERSON AFFECTED
15.
a. LAST NAME
b. FIRST NAME
c. AGE
d. SEX
e. STATUS
f. GRADE
16. CITE NUMBER
17. UNIT OF ASSIGNMENT
18. PATIENT CLASS
19. MOVEMENT PRECEDENCE
(X one)
U
P
R
20. CONTACT INFORMATION OF PERSON AFFECTED
b. TELEPHONE NUMBER (Include area code)
a. ADDRESS (Include ZIP code)
c. E-MAIL ADDRESS
21. DIAGNOSIS
22. MEDICAL EVALUATION TREATMENT RECEIVED
(X and complete as applicable)
YES
NO
N/A
a. DID THE PERSON RECEIVE A MEDICAL EVALUATION AND/OR TREATMENT FOLLOWING THE EVENT?
b. WAS THE PERSON EVALUATED AND/OR TREATED BY A PHYSICIAN ON THE AIRCRAFT OR FLIGHT LINE?
IF YES, CREDENTIALED HEALTHCARE PROVIDER NAME:
c. WAS THE PERSON EVALUATED AND/OR TREATED AT THE MTF?
IF YES, MTF NAME AND LOCATION:
d. IF EVALUATION OR TREATMENT WAS RECOMMENDED, WAS IT REFUSED?
SECTION V - ASSESSMENT
23. EVENT CLASSIFICATION
(X as applicable)
a. EVENT RESULTING IN THE DEATH, NEAR DEATH OR MAJOR PERMANENT LOSS OF FUNCTION.
b. EVENT RESULTING IN TEMPORARY PATIENT HARM AND INITIAL OR PROLONGED HOSPITALIZATION.
c. EVENT RESULTING IN TEMPORARY PATIENT HARM AND EMERGENCY EVALUATION AND/OR TREATMENT.
d. EVENT DID NOT RESULT IN PATIENT HARM, BUT INCREASED MONITORING REQUIRED.
e. EVENT DID NOT RESULT IN PATIENT HARM OR NEED FOR INCREASED MONITORING.
f. EVENT DID NOT REACH PATIENT AND DID NOT RESULT IN PATIENT HARM.
24. DESCRIPTION OF EVENT
(Concise, factual, objective statement)
24.a. IMMEDIATE ACTIONS TAKEN
DD FORM 2852 (BACK), FEB 2011
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