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University of Wisconsin Hospital & Clinics Graduate Medical Education Global Health ... Was the resident's emergency medical insurance provider notified?
University of Wisconsin Hospital & Clinics Graduate Medical Education Global Health Elective Incident Report Form

In the event of a serious health or safety related emergency – initiate the Emergency Protocol immediately by calling the UW Access Center at 1-800-472- 0111.

The UW Hospital Access Center will contact Dr. Carl Getto and connect the resident with their UW Faculty Mentor or Residency Program Director.

After the resident has called their UW Faculty Mentor, the Faculty Mentor will use this form to record details of the incident. The completed form should be submitted to the UW GME office within 24 hours of the initial phone call.

There is space at the end of the form to include additional pertinent information.

Please send this form to Cindy Feuling in the UW GME office by fax (608-263- 9830) or email ([email protected]).

RESIDENT INFORMATION Name of Resident: Name of UW Faculty Mentor: Name of Residency Program Director: Today’s Date & Time: Local Date & Time of Incident: Location of Incident (site, country):

I. NATURE OF INCIDENT (medical, theft, assault, etc.). Describe the incident. Include how and when you heard about the incident, the names of witnesses (if any) and their contact information if available.







II. MEDICAL EMERGENCIES: (if not applicable, skip to part III) Was the resident’s emergency medical insurance provider notified? (circle one) YES NO

If no, please explain why not?

If yes, what was the recommendation of the insurance provider? Did the resident follow the recommendations of the insurance provider?

Was medical attention recommended to the resident? (circle one) YES NO

If no, please explain why:

Did the resident seek medical attention? (circle one) YES NO

If no, please explain why:

If yes, where did the resident seek medical attention? (name and address of doctor / hospital)

What was the result?



III. POLICE OR LOCAL AUTHORITIES INVOLVEMENT: (if not applicable, skip to part IV) Were the police or local authorities notified? (circle one) YES NO

If no, please explain why:

If yes, describe who was notified, who initiated the notification, and the current status. Include with this report any documentation the resident may have (can be included on return), as well clarify if the resident is a victim or an alleged perpetrator.





IV. Additional information or Comments:





V. Report Filed By:

_________________________________________ Printed Name of Person Filing the Report

_________________________________________ Title and Department of Person Filing the Report

_________________________________________ _________________ Signed Name of Person Filing the Report Date





Adapted with permission by Dr. Sabrina Wagner from UW-Madison, International Academic Programs

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