Incident Reporting Form
事故報告表

Please report an incident / near miss using the form below. Click on the "Submit" button at the bottom of the form once completed. Our 1st Line Risk Team will contact you to gather any supporting documents you may have and obtain further details regarding the incident.
Remark: Please DO NOT fill in sensitive personal information of customers/ patients, such as ID numbers

請使用以下表格匯報事故/未遂事故。填寫完畢後點擊表格最下方的“提交”。我們的第一線風險團隊將會與您聯繫以收集與事故相關的支持文件及詳細資料。
注意：請勿填寫客戶/病人的敏感個人資料，如身份證號碼等。

* - Please do not input these special characters in the form: <>&
* - 請勿在表格中輸入以下符號: <>&
* - Mandatory fields
* - 必填

Reporting Staff Information 匯報人員信息

Incident Capture By (匯報人員姓名)

*

Recording User Email (匯報人員電子郵件)

**

Recording User Contact No. (匯報人員聯絡電話)

*

Which BUPA business do you work? (你在保柏哪個公司工作?)

Which Dept./Team do you work? (你在哪個部門/團隊工作?)

Key Information 關鍵信息

Incident Title (事故標題)

*

Summary Incident Description (事故摘要說明)

*

Immediate Action Taken (即時採取的行動)

*

Is It A Near Miss? (是否屬於未遂事故?)

Initial Incident Severity (初始事故嚴重性)

Key Dates 關鍵日期

Occurrence Date (事故發生日期)

*

Identified Date (事故識別日期)

*

Impact 影響

People Affected By The Incident (受事故影響人士)

Generate a new image Play the audio code

Enter the code from the image