CONFIDENTIAL OVR No
Patient name
File No#:
Sex/Age
Must be completed in full
Incident time
Incident Date
Incident Location /Dept
Person Involved patientstaffvisitorothers
Employee
Position
ID No
Department/Unit
Description of Occurrence/ Variance
Incident Risk
LIKELIHOOD Rare -1Unlikely-2Possible -3Likely -4Almost Certain -5
CONSEQUENCES Minimum -1Minor -2Moderate -3Major -4Serious -5
