Incident Reporting Form

Please use this secure form for reporting HIPAA incidents. If you need assistance, please call the HIPAA Office at 501-603-1379

Report an Incident Using this form

REPORTER INFORMATION

Person Reporting: Title (If UAMS Employee):
Department (If UAMS Employee):
Address: City: State: Zip:
Phone: Alternate or Mobile: Fax:
E-mail:
Date UAMS Became Aware:
Date Incident Occurred:

EMPLOYEE INFORMATION

Name: Title: Department:
Phone:
Alternate or Mobile: Fax: E-mail:

PATIENT INFORMATION

Sal: Last Name: First Name: MI:
DOB: MRN:
Address: City: State: Zip:
Phone:
Alternate or Mobile: Fax: E-mail:

OTHER CONTACT INFORMATION

Contact Name: Other Org. (If Applicable):
Address: City: State: Zip:
Phone: Alternate or Mobile: Fax:
E-mail:

Contact Notes:



Please describe the incident as completely as possible:


Requires Response Before Submitting, If you see Harley the Hippo, type "eyesee" in the text box below: