Get Ga Dch X-ray Incident Reporting Form 2014-2025

Filing the GA DCH X-Ray Incident Reporting Form online is a vital process for documenting incidents related to x-ray exposures. This guide provides clear and supportive instructions to help you complete the form efficiently and accurately.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling out the facility information section, which includes the name of the facility, facility type, x-ray registrant number, address, city, state, and zip code.
3. Next, provide your contact information in the 'Person Reporting Incident' section. This includes your title, name, contact phone number, fax number, and email address.
4. Proceed to the 'Patient / Reporting Information' section. Fill out the relevant dates and times, including the date and time the incident was reported, the date and time the facility became aware of the incident, and the date and time when the incident occurred.
5. In the 'Affected Patient or Employee Information' section, enter the name, age, sex, medical record number (if applicable), date of admission, date of birth, and diagnosis of the affected individual.
6. Indicate the type of incident by checking the appropriate boxes. This includes various categories of overexposure and unauthorized exposure outlined in the form. Be sure to attach a copy of any additional incident reports if necessary.
7. Describe the circumstances of the incident briefly in the provided space. If more space is needed, attach an additional sheet.
8. Next, check all applicable categories of staff involved in the incident, including radiologists and radiological technicians.
9. Document any immediate corrective or preventative actions that were taken post-incident. Again, you may attach an additional sheet if necessary.
10. If the incident involved a death, answer the questions regarding the notification of the medical examiner and whether an autopsy was requested. Ensure you provide the name and contact number of the medical examiner if applicable.
11. Finally, complete the acknowledgment section by affirming that the information provided is true and accurate to the best of your knowledge. Sign and date the form, and print your name where indicated.
12. Once you have completed the form, save your changes. You may choose to download, print, or share the form as needed.

Ensure you complete your reporting promptly by filling out the form online.