New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Incident Report Form
(Required pursuant to N.J.A.C. 13:30-8.8)
Note: The Board’s regulations state that licensees must submit a report, within seven days, of any
incident occurring in a dental ofce, clinic or other dental facility, which requires the removal of a patient
to a hospital for observation or treatment. Licensees are also required to report any death which may be
related to dental treatment, whether or not the death occurred in a dental ofce, clinic or other facility.
Date of report
Practice name
and address
Name and signature
of treating dentist
Name and signature of the
individual making the report
(if not the treating dentist)
Patient’s name
Patient’s age and gender
Date and time of the incident
Patient’s medical history (include
all medications, vitamins, herbal
supplements, etc.)
Dental procedure at
the time of the incident
Duration of the dental procedure
prior to the incident
Drugs administered to the patient prior
to the incident (include local, sedative
and/or general anesthetic agents;
amount, type and dosage)
Signature:
This form is a llable PDF le. It must be lled out electronically, printed and mailed to the board, or
printed and lled out using a typewriter. You should also submit copies of the patient’s medical history
form(s), a copy of the ofce emergency protocol (including staff assignments), and a copy of any
medical consultation(s) if required prior to treatment.
Signature:
