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Get UT Patient Safety Sentinel Event Reporting Form 2007-2024

___  Person Reporting  _______________________________  Email  ______________________________  Telephone  ______________________________  Title  2.  PATIENT INFORMATION  Patient DOB: ________  Age____  Gender:  F___ M___  Principal Admitting Diagnoses  Date of Admission ______________  (ICD code if known)  (possibly preloaded)  _______         ____________________  _______         ____________________  _______         _____________.

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