Healthcare professional (HCP) and social care complaint/enquiry form

Please use this form to record any incident you wish to make on behalf of your organisation in relation to the care we have provided, giving as much information as possible. To ensure we are able to gather the information in a timely manner please choose the exact service you are referring, choosing the risk score you believe it should be handled.

Name*
Job title*
Organisation / Practice*
CCG*
Address*
Contact number*
Email*
Date*
DD slash MM slash YYYY
Patient details (where necessary)
Please give name, address and date of birth OR NHS number
Name
Address
Postcode
Contact number
Date of birth
DD slash MM slash YYYY
Sex
- Male
- Female
NHS number (if available)
Ethnicity
Date of incident
DD slash MM slash YYYY
Time of incident

: Hours

Minutes

AM/PM
NWAS incident number (if known)
Service provided by NWAS
- PES - emergency ambulance (999)
- PTS - patient transport service
- 111 - Telephone Service
- 111 - Online Service
- Urgent care
- VAS - voluntary aid sector (eg, St John)
Is your request part of an ongoing SI/PSIRF investigation? If yes, please provide your SI number
Details of incident (please do not use abbreviations)
Patient outcome (without patient outcome, we cannot investigate this incident thoroughly/ in its entirety)*
Result
Degree of harm
File upload
Drop files here or

Max. file size: 50 MB.
For associated files such as incident report forms or patient report forms
Risk score (download risk score matrix below)*
Consent*
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