Event Form: Wellbeing and Safety

Fields marked with an * are mandatory.
Please note: All Event Forms go to one of the Designated Officers (DOs) of the School of Medicine for review and triage and further action. If required, please see the document Event Form and Associated Guidance 2017/18 for further information.
Please note: This Event Form can be completed by students and staff.

Details of Concern or Incident

If this information is CONFIDENTIAL, please tick this box

*Date:

*Time:

*Location:

*Describe your concern:

*Who or what does the Concern relate to? Or Who is/was involved?:
Please give relevant details of who is/was involved, their position or course, including year group. Contact information of relevant staff and/or students are helpful. Don’t include patient identifying information.

If this is about a person, do they know you are submitting a Wellbeing and Safety Event Form?

*In Patient Safety Events: Has a DATIX/IR1 Form been completed?

Please give details:

*Details of any impact if relevant?
Consider the student, their peers, patients, the public and staff, the School, the NHS, etc:

*What, if any, action has been taken so far:

Your Details

*Name:

*Position:

*Organisation:

Telephone:

*Email:

Declaration

*The information contained within this form is to the best of my knowledge factual accurate and a true account.
I understand that submitting false or malicious information is a fitness to practice and / or disciplinary offence.
I confirm I understand and agree with the above.

Thank you for completing this Event Form.