Complaint Incident

Section 1. Nature of the complaint / Incident

Date & Time of Incident/Complaint:* “Please enter as dd/mm/yyyy hh:MM AM/PM”

How was this complaint made?:*

Section 2. Your details

Your First Name:*

Your Last Name:*

Your contact e-mail address:*

Has your manager been informed?:*

Name of Manager:*

Section 3. Details of person (s) making complaint or is involved with the incident

First Name:*

Last Name:*

Patient ID:


Email address (If preferred):

Section 3.1
Related Contact details with the person making a complaint or is involved with the incident

Other Contact:

Other Contact Phone Number:

Section 4. Location of the case

Medical Centre:*

Specific Area:*
Specific Area (Other):

Staff involved with this case:

Section 5. Description of Incident/Complaint

Was an ambulance called?:

Section 6. Follow up action to be taken

Follow Up Actions Planned:

Investigation:

Current control in place:

Controls to be implemented:

SAC Score:*

Any other information?:

Section 7. Attachment

Files will be requested in a follow up email to your case

I want to attach files to this case