Hospital Power Outage Incident Report Form
Date of Incident
Time of Incident
Reported By (Name & Position)
Department/Unit
Location of Incident (Building/Floor/Room)
Duration of Power Outage
Areas Affected
Backup Generator Activated?
Yes
No
Effect on Patient Care/Services
Suspected Cause (if known)
Immediate Actions Taken
Reported To (Name/Position)
Additional Notes/Recommendations
Signature
Date