CST Investigation Outline for a Reportable Incident Form

  • Mandatory Reporting & Documentation

    Within one (1) working day after discovering a reportable incident, the Facility Medical Director must notify CPSA at 780-423-4764 or 1-800-561-3899.

    Within two (2) weeks of the incident the facility must submit this form, which includes uploading a copy of the patient’s complete clinical record and a narrative summary from the physician most involved with the case.

    The Deputy Registrar may review the circumstances with the Medical Director and may consult with other practitioners to determine the risk of harm to patients. If necessary, the Deputy Registrar may suspend the accreditation of any facility on a suspicion of continuing risk.
  • This is the email address we will send a submission confirmation notification to.
  • General Information

  • Date Format: MM slash DD slash YYYY
  • (Must be a regulated health professional)
    First NameLast NameTitle/positionPhone 
  • Patient Information

  • Description of the event

  • History of the event

    Describe contributing factors to the incident for each of the following, as applicable:
  • Facility response to the event

  • Additional documents

  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Accepted file types: jpeg, png, jpg, tiff, pdf.
  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Accepted file types: jpeg, png, jpg, tiff, pdf.
  • Signature

  • Date Format: DD dash MM dash YYYY
  • This report is prepared for the Medical Facility Accreditation Committee (MFAC) and is privileged and confidential under Section 9 of the Alberta Evidence Act.