Submit a request – Clipboard Health

Please choose your issue below

Your email address

Who is completing this form?

What would you like to report?(optional)

Which party are you reporting?(optional)

What is the name of the person you wish to report(optional)

Full name of the Clipboard Health professional that is involved:

First Name

Last Name

Please Specify(optional)

Was anybody physically Injured?

Does/did your injury require medical treatment?(optional)

You may be entitled to assistance with medical costs related to your injury if you seek medical treatment.

Is a patient at risk of being harmed?(optional)

Who is impacted by this incident?

(Select all that apply)

If 'Other' please add more information

Enter your first name(optional)

Last name(optional)

Telephone number(optional)

Enter Title(optional)

What was the facility type for the shift in question?(optional)

Facility Contact that is involved:

First Name

Last Name

Date Incident Occurred:

Subject

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

Did the above incident have any impact on your attendance score?

Name of the Workplace/Facility where the incident occurred:

As shown in mobile app

Email Address of the Workplace/Facility Contact that is involved:

Phone Number

Workplace/Facility contact person phone number

Email Address of the Clipboard Health professional that is involved:

Phone Number of the Clipboard Health professional that is involved:

Attachments(optional)

Add file or drop files here