Documentation of Adverse Effects/Potential Harm

Date of Incident *

Date of Report *

Report Filed by *

Your Credentials *

Contact Phone Number *

Email *

1. Type of Adverse Effect and/or Potential Harm: *

Check all that applyAdverse Health EventsFalsely Claimed CredentialsFinancialInaccurate or Misleading InformationQuestionable TestsOther, please specify below:

2. Source of Adverse Effect and/or Potentially Harmful Nutritional Advice: *

Check all that applyChiropractorDietitianHealth CoachHealth Food Store PersonnelNaturopathNutritionistPersonal TrainerOther, please specify below:

3. Describe the adverse event or potential harm that occured: *

4. What was the outcome of this incident? *

Additional Medical CareDeathDisabilityHospitalizationPotential Harm: harm could have been done, but health professional or dietitian convinced client to stop using product or disregard harmful adviceSide EffectsWasted MoneyOther, please specify below:

5. In the event we go to the legislature in the future to advocate for changes in our licensure law, would you be willing to submit testimony about this incident? *

YesNoNot sure

6. In the event we go to the legislature in the future to advocate for changes in our licensure law, would the patient/consumer be willing to submit testimony about this incident? *

YesNoNot sure

Documentation of Adverse Effects/Potential Harm

Documentation of Adverse Effects/Potential Harm caused by Unsafe Practice

Background Information

Adverse Effects/Potential Harm Report

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