Mandatory fields are marked with an asterisk (*)
Form date: 11.4.2026
Form author:
Patient/customer Relative Other reporter
Date and time of the incident: *
Date:
Time: 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 : 00 10 20 30 40 50
Where event happened: *
What happened and how did it happen? What were the consequences? *No personal data (such as personal identification number, name) in the event description
What can be done to prevent the incident.:
Select one of the following: *
I wish the report to be forwarded to the persons responsible for the operation, and to be contacted when my report has been processed. I wish the report to be forwarded to the persons responsible for the operation for handling, but I do not wish to be contacted. I wish the report NOT to be forwarded to the persons responsible for the operation, but for information to the quality unit to be handled at a general level.
If you want a response to your notice, please leave your contact information:
E-mail address:
Other contact information:
I accept service's privacy policy: *
Yes