Free Incident Report Template 31Free Incident Report Template 31
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Incident reporting form
[Insert name of dental practice]
Please use this form to report the details of any actual or potential incidents that affect the
confidentiality and security of patient information; it should then be given to the practice’s IG
lead [insert name or alternative contact] for further action.
General information
Register number - to be added by IG lead [insert alternative post]:
Reported by:

Date/time discovered:

Incident details
Type of incident [tick a category]:
 Confidentiality e.g. breach due to unauthorised access, potential breach due to lost record,
 Integrity, e.g. records altered without authorisation, etc;
 Availability, e.g. records missing, mis-filed, theft etc.
Incident details, state the facts only, where it occurred; what information was involved; etc:

Initial action(s) taken, what did you do, who will/have you reported to:

Date reported:

Investigation and management
[Insert name and post of person investigating the incident]
e.g. Informa