Use only after a real event with authorization. Repeat for relevant tasks or opportunities, including successful use, non-use or no opportunity. Keep this separate from CPX ratings.
- Incident code / team code / form version
- Enter _____ / _____ / _____. Use institution-authorized codes; omit names, personal IDs, phone numbers and person-identifying coordinates.
- Incident date and interval
- Start _____ end/ongoing _____ time zone _____ record date _____. Mark unknown times; label estimates explicitly.
- Prior training and actual interval
- Training code/version _____ completion date _____ trained behavior _____ incident start _____ interval _____ days; refresher/other activities and dates _____.
- Permissions and custodian
- Permission reference/scope _____ institutional custodian _____ required use basis/consent/review _____ access _____ review/deletion date _____. Do not attach sensitive records to a public copy.
- Actual team and roles
- Roles/member codes _____ continuing trained members _____ / whole team _____ role/personnel changes, dates and reasons _____. Distinguish organization from team continuity.
- Linked criterion and opportunity
- TC-_____ expected behavior _____ trigger/time offering opportunity _____ verified duty/authority _____ constraints _____. If no opportunity, enter NO and why.
- What actually happened
- Action/non-action _____ time _____ role _____ observed consequence _____ unknowns _____. Separate facts from causal explanations.
- Contemporaneous records
- Record code/version _____ creation time _____ page/item/timestamp locator _____ custodian _____ de-identified summary _____ missing items/reasons _____. Do not provide public links exposing incident records.
- Later recollection
- Informant code/role _____ collection date _____ days after event _____ method _____ recalled account _____ uncertainty _____. Keep separate from contemporaneous records even for firsthand respondents.
- Corroborating and contradictory evidence
- Supporting code/locator _____ contradicting code/locator _____ independent source or copied account _____ checks made _____ unresolved discrepancies _____. Do not select only successes.
- Context and confounders
- Incident scale/severity _____ workload _____ staffing/resources/communications _____ plan changes _____ other incidents/training _____ external support _____ differences from CPX _____.
- Transfer interpretation and evidence confidence
- Select: evidenced use / opportunity but non-use / unsuccessful adaptation / no opportunity / insufficient evidence. Reasons and evidence codes _____ plausible training contribution _____ alternative explanations _____. Do not automatically infer causality.
- Harms, risks and safety follow-up
- Record separately from learning scores: harm/near miss _____ evidence _____ urgency _____ institutional reporting route _____ coded owner _____. Do not delay urgent action for assessment.
- Improvement, owner and due date
- Evidence-supported problem _____ action _____ owner role/code _____ due date _____ closure evidence _____ constraints/escalation _____.
- Recheck date and result
- Review date _____ reviewer code _____ method/evidence _____ actual result _____ closed/open/reopened _____ reason _____ next review _____. Closure labels do not substitute for evidence of an effective correction.
- Independent review and disagreement
- Reviewer codes _____ each independent interpretation _____ evidence used _____ disagreement _____ consensus/unresolved _____ reasons _____. Retain originals separately from consensus.
- Missing and inapplicable fields
- Field ID _____ NO: unknown/unobserved/no opportunity because _____ or NA: outside scope because _____ reviewer _____ date _____. Explain blanks and do not replace them with zero.
