Transcription of MEDICAL BOARD OF CALIFORNIA
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MEDICAL BOARD OF CALIFORNIA
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY - Department of Consumer Affairs EDMUND G. BROWN JR., Governor MEDICAL BOARD OF CALIFORNIA (REVISED 01/2018) 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2382 (800) 633-2322 FAX: (916) 263-2944 ADVERSE EVENT REPORTING FORM FOR ACCREDITED OUTPATIENT SURGERY SETTINGS Business and Professions Code (B&P) section makes accredited outpatient surgery settings subject to adverse events reporting requirements as follows: Facilities shall report an adverse event no later than five days after the adverse event has beendetected, or If that event is an ongoing urgent or emergent threat to the welfare, health, or safety of patients,personnel, or visitors, no later than 24 hours after the adverse event has been Information Facility Name: Facility Address: Contact Person Preparing Report: Contact Phone Number: Practitioner Information Name of Practitioner Performing Procedure: License Type/ License Number: *Patient InformationPatient s Name: (Last, First, Middle) Patient s Address.
Yes No . Name and address of hospital (if applicable): Please check the appropriate Adverse Event Category. In addition, check the Adverse Event
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