1. a) The name, address and Department-assigned unique identifier of the health care facility making the report;

2. b) The name, title and contact information of the person making the report;

   1. c) The exact location within the health care facility where the adverse health care event occurred;

3. d) The date and time that the adverse health care event occurred;

   1. e) The date and time that any employee, contractor or representative of the health care facility was notified of the occurrence of the adverse health care event;

4. f) Gender and age (range) of the patient;

   1. g) Race or ethnicity of the patient;

      1. h) Language spoken by patient; if the language was not English, was a translator present;
5. i) Date on which the patient was admitted;
6. j) Admitting diagnosis code of the patient;

7. k) Principal procedure code of the patient if the event involved surgery;

   1. l) Description of the adverse health care event, including number and type of staff present at time of the event;
   2. m) Any immediate or emergency remedial actions taken prior to filing the adverse health care event report, including if the patient and/or the patient's family was informed of the event; and
8. n) The outcome for the patient from the adverse event.

Reports of adverse health care events required. Each health care facility shall report to the Department the occurrence of any of the adverse health care events described in Section 235.130 of this Part no later than 30 days after discovery of the event. (Section 10-15(a) of the Act) The reports required by the Act and this Part may be filed by electronic means. The electronic system shall have uniform reporting templates, automated report receipts, a user "save" feature and automatic reminders to report the 90-day Root Cause Analysis and Corrective Action Plan. Reports of adverse health care events shall include: