Is There a Request for Privacy? (If yes is ticked, the confidentiality policy will be applied for the reporting and sharing of reports.)
If no:
Name and Surname:

Where the Incident Occurred:
When the Event Occurred:
Subject of the event:
Drug Safety:
If other:
Surgical Safety:
If other:
Prosthetic Laboratory Safety:
If other:
Development Process of the Event:
Your Opinions and Suggestions, If Any:
• Subject of the Incident and Opinion-Suggestion sections are required to be filled.
• The event should be described in the notifier's own words.
• Notification forms are evaluated by the Quality Management Unit in terms of compliance with the rules. Notifications sent in accordance with the rules are forwarded to the Related Committee / teams.
• In case of a confidentiality request, the incident is only discussed in the relevant committee. Especially in the reporting and sharing of reports, the confidentiality principle is applied.
• If this form is filled manually, it should be sent to the Quality Management Unit after it is filled.
• Thank you for your sensitivity.
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