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You are currently viewing the Consumer Report form. If you are a Clinician, please use the clinician report form to report your incident or near miss by clicking here

We ask consumers/patients to report your experiences to find out directly what went on when you, or someone you know, was in the emergency department (ED). The patient and their family/carer can often see most clearly how things could be improved or how an experience could have been prevented.

Your information will be combined with other reports, analysed and fed back to emergency doctors and doctors in training.

The information may be used at conferences, presentations and in research papers, however it will be de-identified to maintain your anonymity. To assist with this anonymity, please write Dr A or Nurse B instead of using the person’s name.

Please enter incident details below - mandatory fields are marked with an asterisk (*).
Please select an option from the list below.

Describe what happened using clear, non-identifiable wording.

Describe the final outcome of your experience.

Describe how you think your experience could have been prevented.

Describe what you think the emergency department could have done better.

Please enter your / the patient's age at the time of the experience.

Please enter the gender.

Enter the correct numbers into the box below
Please enter the numbers into the box