Family Safety Reporting Form

Please use this form to report quality and safety concerns regarding the inpatient wards.

Please be assured that completing this form is completely voluntary and will have no effect on the medical care you receive here at MassGeneral Hospital for Children.

If you have any questions of an immediate nature, please contact the Clinical Nurse Specialist at 617-724-5720 or the Director of Pediatric Quality and Safety at 617-726-1450 or via email at SpeakUp@partners.org.

Required fields are marked with an*

Location

If other, please specify

Date

Staff involved (name and position)

Please describe your safety and/or quality of care concern

What was most troublesome to you?

Did you tell anyone of this event?

If so, who? Were they helpful?

If no, why not?

Did you feel that the issue was resolved? Please explain.

Do you have any suggestions to avoid this problem in the future?

Patient name

Phone

Street address

City

State

Zip code

Your name/relationship to patient

E-mail address

I prefer to file this report anonymously