Mandatory fields are marked with an asterisk (*)
Form date: 13.8.2026
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. Please note that, for data protection reasons, client or patient information can only be handled with the individual themselves or with persons who have the right to access such information 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