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Event Entry
* Facility: 
* Event Type: 
Event Information
* Event Date/Time: * Discovered Date/Time:
* Event Department:
        Did event involve a patient? No Yes
* Patient Information
Type of Visit:
Patient/Subject First Name:  Last Name:   Date of Birth: (mm/dd/yyyy)   Age:  
Gender: Male Female Primary Patient MRN or Account # (If unknown, enter 1234):  
Family/Friend/Companion Aware:  No Yes Unknown
    * Was there a patient injury?:  No Yes Unknown
Provider Notified:
No Yes Name:  Notified Date/Time:   Time Ex: 1315
Additional Event Information
Employee Reporting Event:  Room#/Section:  Primary Witness: 
* Event Description
 
 
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This report will be labeled as Quality Assurance Information (Performance Improvement), compiled in accordance with statute and regulation and in accordance with the State Education Law 6527 and Public Health Law 2805(m).
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