GSCH Online Occurrence Report
This document is confidential as part of Greater Seacoast Community Health's Quality Assurance Program Review pursuant to New Hampshire RSA 329:29-a
Do not include or upload any Personally Identifiable Information (PII) or Protected Health Information (PHI) in this form.
This form is not intended to collect sensitive personal or medical data.
Submitted By
First Name
Last Name
Submit anonymously
Yes
No
Has your supervisor been notified?
Yes
No
Supervisor Name
Date Incident Occurred
*
-
Month
-
Day
Year
Date
Department Impacted by Incident
Please Select
Behavioral Health
Call Center
Dental
Family Center
Family Services
Front Office
LabCorp - on site
Maintenance
MAR
Medical Records
Mobile HC
New Patient Coordination
Other
Pharmacy
Prenatal
Primary Care
Referrals
Resident Program
Somersworth SB Program
Triage Nurses
WIC
Type of incident
*
Please Select
Patient Safety Report
Staff Involved?
Yes
No
Staff Involved
add name(s) of staff involved
Patient Involved?
Yes
No
Patient MRN (external ID ONLY!)
add patient ID# from EMR
GSCH Site of Incident
Please Select
FF
GCH
HCH-Van/Mobile location
Somersworth School-Based Program
Other
Specific Location
Detailed Description
Immediate action taken
*
Other services/depts involved in Incident
Please Select
Internal behavioral health provider
External behavioral health provider
Community Partners
Police
Social Work
MAR
SOS
None
Other
Unknown
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