Friday April 18, 2014 |

[Confidential] Patient Safety Incident Report Form

Patient Safety Incident Report Form

Please fill out the form and click on the button below to submit your incident report.
If you have any questions, please contact Carolyn McKay at Ext. 271.

Date of Incident

Time of Incident

Person(s) involved - Position(s) Relation to Care Resource (required)

What happened / Describe the specifics of the incident

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Care Resource Audit

FTCA Health Center

This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

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Locations

3510 Biscayne Blvd.
Miami, FL 33137
T. 305.576.1234 | F. 305.571.2020


871 West Oakland Park Blvd.
Ft Lauderdale, FL 33311
T. 954.567.7141 | F. 954.565.5624


1701 Meridian Avenue, Suite 400
Miami Beach, FL 33139
T. 305.673.3555 | F: 305.673.1960

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