Columbus Free Clinic Incident Report

This form is intended to give patients, volunteers, and staff a way to share concerns or report incidents related to care, safety, conduct, or any other issue experienced at the Columbus Free Clinic. Whether you’ve encountered a problem with your care, witnessed something concerning, or want to bring attention to an area where we can improve, we encourage you to let us know.

Reports can be submitted anonymously. If you would like us to follow up with you, please include your name and contact information in the optional contact section. All submissions are taken seriously and help us maintain a safe, respectful, and high-quality clinic environment for everyone.

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Date of Incident *
MM
/
DD
/
YYYY
Time of incident
Time
:
Location of incident or concern (specific area within the clinic): *
Please write a description of the incident or concern:  *
Role of person completing this form (e.g., volunteer, provider, staff, patient, loved one, etc.) *
Name of others involved and their roles (if any):
(Example: Kyle Smith - Patient)
Witnesses to incident and their roles (if any):
(Example: Martha Moore - Steering volunteer)  
Was anyone from the Columbus Free Clinic notified at the time of the concern? 
Clear selection
If yes to the previous question "Was anyone from CFC notified at the time of the concern" Please list the name of the person notified if you know it: 
Additional comments, questions or concerns: 
OPTIONAL: Contact Information if you would like us to follow up with you:  (Your name, email, phone number)
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