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 incident occurred: incident occurred: where the 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
Country:*Required
Organization Phone Number:
Organization Street Address:*Required
City:*Required
State:*Required
Zip Code:*Required
You have the option to submit this information anonymously or you may provide your personal information if you wish to know the status of your
   Safety event. Your name/identity as the source will be kept confidential unless you allow us to share your name with the organization.
Complete the information below if you would like The Joint Commission to notify you about the status of 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
Salutation:
First Name:
Middle Initial:
Last Name:
Suffix:
Professional Credentials:
Street Address:
City:
State:
Zip:
Telephone: Ext:
Fax: Ext:
Email:
Your Company Name:
Incident Information
Date safety event occurred(mm/dd/yyyy): *Required
Incident Narrative: Provide a brief overview of your safety event. Please limit your narrative to 3 pages (15,000 characters). You may attach a document(s), to support your concerns, however, the Incident Narrative must be filled in first, and be submitted, in order for document attachments to be uploaded. *If you wish to upload a document, you will be able to after submission on the next page. *Required
Disclaimer (Please read the disclaimer before submitting your safety event)