Please do not use any information that can identify patients. Please use patient initials as needed.

Send any pertinent medical records to ClinicalQuality@azas.team (HIPAA Compliant email)

Name of CRNA Reporting: *
Name of CRNA Reporting:
Name of CRNA Involved
Name of CRNA Involved
If same as person reporting, use "SAME"
Date of Incident *
Date of Incident
Checkbox *