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Get GA DCH X-Ray Incident Reporting Form 2014-2024

Dch. georgia.gov X-RAY INCIDENT REPORTING FORM Please type form FACILITY INFORMATION Name of Facility Facility Type X-Ray Registrant Address City State Zip Code Person Reporting Incident Title Contact Person s Contact Phone Fax Email Address PATIENT / REPORTING INFORMATION Date Time a.m. /p.m. Reported to Healthcare Facility Regulation Division a.m. /p.m. Facility Was Aware of the Incident a.m. /p.m. Incident Occurred Affected Patient or Employee Name Age Sex Patient Med Rec as applicable Date of Admission Date of Birth Patient s Diagnosis TYPE OF INCIDENT Please check appropriate boxes. Attach a copy of incident report if applicable Over exposure of the whole body to 5 rems or more Exposure of an individual to radiation in excess of any applicable limit set forth in the rules Levels of radiation in an uncontrolled area in excess of 10 times any applicable limit set forth in the rules Page 1 of 2 Briefly describe circumstances of the incident Attach additional sheet if necessary CATEGORY OF STAFF INVOLVED IN THE INCIDENT Check all that apply Radiologist Radiological Technician Other Specify Immediate Corrective or Preventative Action Taken attach additional sheet if necessary Note If the incident involved a death was the medical examiner notified Was an autopsy requested YES NO Name and contact number of Medical Examiner N/A Acknowledgement of Information Reported I attest that the information reported within this form is true and accurate and completed to the best of my knowledge. Attach a copy of incident report if applicable Over exposure of the whole body to 5 rems or more Exposure of an individual to radiation in excess of any applicable limit set forth in the rules Levels of radiation in an uncontrolled area in excess of 10 times any applicable limit set forth in the rules Page 1 of 2 Briefly describe circumstances of the incident Attach additional sheet if necessary CATEGORY OF STAFF INVOLVED IN THE INCIDENT Check all that apply Radiologist Radiological Technician Other Specify Immediate Corrective or Preventative Action Taken attach additional sheet if necessary Note If the incident involved a death was the medical examiner notified Was an autopsy requested YES NO Name and contact number of Medical Examiner N/A Acknowledgement of Information Reported I attest that the information reported within this form is true and accurate and completed to the best of my knowledge. Name of Person Completing Form Date Completed Print Name For Department Use Only Received in S/A Date Reviewed By Reporting time frame met Yes No Action Required Yes No Self Report ID Complaint This report is required as set forth in the X-ray Rules 290-5-22-07 2 and 4 Revised 11/26/2014. Nathan Deal Governor Frank Berry Commissioner 2 Peachtree Street NW Atlanta GA 30303-3159 404-656-4507 www. dch. georgia*gov X-RAY INCIDENT REPORTING FORM Please type form FACILITY INFORMATION Name of Facility Facility Type X-Ray Registrant Address City State Zip Code Person Reporting Incident Title Contact Person s Contact Phone Fax Email Address PATIENT / REPORTING INFORMATION Date Time a*m* /p*m* Reported to Healthcare Facility Regulation Division a*m* /p*m* Facility Was Aware of the Incident a*m* /p*m* Incident Occurred Affected Patient or Employee Name Age Sex Patient Med Rec as applicable Date of Admission Date of Birth Patient s Diagnosis TYPE OF INCIDENT Please check appropriate boxes. .

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