Event Form: Wellbeing and Safety

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.

The information you provide will inform our actions around our School of Medicine Event Form Reporting system.

It might be forwarded verbatim to the person your form is about or it might be sent in a paraphrased format.

If you would like to amend your form after sending it or withdraw altogether, please email us to discuss. If you wish for us to send you the full Event Form Guidance, please email us.

The information from this event form will be kept by the School of Medicine according to UCLan’s Retention Schedules.

For medical students transferring to the UK Foundation Programme, the records are also kept until they have completed the first year of the NHS Foundation Programme, whichever is the longer.

We potentially are required to share information with relevant regulatory bodies; there are Transfer of Information agreements in place. Examples for this are NHS Foundation Schools and the GMC (General Medical Council).

To protect patient safety, information might also have to be shared with NHS organisations, this will follow data sharing principles. Read further information about NHS Data security and information governance. Anyone we share information with is under the obligation to process such information securely and in accordance with the current data protection legislation.

Fields marked with an * must be completed.

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.

Keep In Touch – Your Communication Preferences

We may need to contact you regarding this form. How would you prefer us to do this?

Yes! I would love to receive communication by:

Phone

Text Message (SMS)

If you’d prefer not to hear from us, you can withdraw your consent and stop receiving our updates at any time by getting in touch.

Data Protection

Here at The University of Central Lancashire we take your data and your privacy very seriously and we’ll treat it with the utmost care and respect. By providing your details above, the University will process your personal data in compliance with data protection legislation and only process for the purpose collected unless there is a lawful basis to do so.

If you would like more detailed information relating to this or your rights, or who to contact if you have any concerns about the use of your personal data, please go to the privacy policy published on our website.

We will not share your personal details or your information with any third parties unless this is to enable them to process that data on our behalf. Such third parties will be bound by an obligation to process such information securely and in accordance with the current data protection legislation.