Health Care Organization Information
Complete the three steps below. In step 3, only health care organizations accredited/certified by The Joint Commission are included in the list.

1. Select the state/country 2. Select the city where the 3. Select the health care organization where the
where the incident occurred: incident occurred: incident occurred:

If you DID NOT find the name of the health care organization from the list in step 3 above or the address below is incorrect, Press and please complete the information below.

Type of Organization:
Organization Name:*Required
Organization Phone Number:
Organization Street Address:
Zip Code:
Personal Information
Complete the information below if you would like The Joint Commission to notify you about any action taken on
your safety event. Your name will be kept confidential.

I am: *Required
Do you wish to remain anonymous? *Required
May we contact you if we need more information related to the incident? *Required
First Name:
Middle Initial:
Last Name:
Professional Credentials:
Street Address:
Telephone: Ext:
Fax: Ext:
Your Company Name:
Incident Information
Incident Date: *Required
Incident Narrative (Provide a brief overview of your safety event. Please limit your narrative to 3 pages (15,000 characters)) *Required
Disclaimer (Please read the disclaimer before submitting your safety event)