Property Event
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Property Event
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Section 1: Initiator Details
Initiator name
*
Initiator's email
Initiator department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Date of occurrence
*
Time of occurrence
*
Other Initiator Department
*
Location of occurrence
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Other
*
Room #
Additional details
Section 2: Occurrence Details
Property Belongs to
*
Patient
Visitor
Staff
Contractor
Hospital
Name
*
DOB
FIN number
Name
*
Related patient name
Phone
*
Address
Name
*
Department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Name
*
Related department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Phone
*
Company name
Event / Incident Reason
*
Damage
Missing
Theft
Vandalism
Trespassing
Other
Property Name
*
Other Event / Incident Reason
*
Law enforcement called
Yes
No
Did they respond ?
Yes
No
Action Taken
Yes
No
What action was taken ?
Description of event
Submit
