The following information will help you collect pertinent information about incidents that patients report while completing Qnaires. The more information  you can share with us, the better we can help you investigate the issue. 


Please collect the following information from the patient:

How was the individual accessing the questionnaire? 

  • Phone (Indicate the cellular device type e.g. iPhone)

  • E-Mail (Indicate the web browser e.g. Internet Explorer)

Describe the nature of the incident: 

  • What happened?

  • What error screen the patient saw?

  • Which Qnaire and which question? 

  • Where were they when completing the Qnaire?

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