Medical Harm Timeline
& Record Organizer
Describe a Serious Hospital Injury, Unsafe Event, or Fatality
Purpose:
This questionnaire is designed to help patients and families organize important information about a serious hospital event. After you fill in the form, save it and download the form as a PDF. The form uses check boxes and short-answer sections to help individuals describe what happened in a structured, brief way. No optional personal data will be revealed to any third party at any time.