Download - Dona Ana Community College

DACC Nursing Program Student Handbook 2012-2013APPENDIX – JDOÑA ANA COMMUNITY COLLEGE NURSING PROGRAMClinical Incident Report FormStudent Error/Needle Stick Injury/Accident, Injury, or Illness(Actual or Potential)Date of Incident: _______________ Time of Incident: ________________________________Location of Incident: ____________________________________________________________Name of Student/Employee: ______________________________________________________Briefly and objectively describe the events of the exposure/incident/ error (actual/potential):Physician notified:Name Orders (if applicable):Describe the evaluation and any treatment following the exposure/incident/error (actual/potential):Follow-up required and person responsible: _________________________Date: __________Incident Report filed at:(Clinical Facility/Institution)Signature of person preparing report: _______________________________ Date: __________Signature of Clinical Faculty (where applicable): ______________________ Date: __________Signature of Clinical/Semester Lead: _______________________________Date: __________Signature of Nursing Program Director: _____________________________ Date: __________Copy to:StudentNursing Program Director/Incident Report FileCreated: July 201159 | P a g e