Heart of Florida Health Center eTracker - Incident Management System

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Heart of Florida Incident Reporting Form

This is Heart of Florida Health Centers’ internal incident reporting system. While anonymous reports are accepted, providing your name and as much detail as possible allows for a thorough review. This system is not for emergencies—do not use it to report events that present an immediate threat to life or property. Reports may not receive an immediate response. All reports are handled under established retention and review procedures, and confidentiality is protected. If you have questions, please contact the Chief Compliance Officer via Teams, email, or phone at x7068

Person Reporting The Incident Please Enter Your Information below or Click Anonymous to Skip
Anonymous:

Reporter First Name *:

Reporter Last Name *:

Reporter Email:

Reporter Phone:

Please fill out information about the incident below.

Please click on who this Incident Involves. You may only select one*:
Patient Employee Visitor

Account No.:

Please enter this persons Name

Patient First Name

Patient Last Name

How many other people involved
Please enter the Names of people involved.

Please select the date and time the incident occurred*:

Please select the location from the drop down

Please attach documents if needed. There is a file size limit of 4MB

Please select the incident category from the drop down

Please provide details about the incident below*:

Heart of Florida Incident Reporting Form

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