# UE Event Form Template

**Complete within 1 hour of event.**

## Event Details

- Event date:
- Event time:
- Unit/room:
- Patient identifier:
- Vent day at event:

## Immediate Clinical Context

- Primary reason for intubation:
- RASS immediately prior:
- Sedation/analgesia at event:
- Restraints present: Yes/No
- If yes, intact/circumvented:
- ETT securement method:
- ETT depth prior to event:

## Event Classification

- Suspected primary etiology:
  - Patient factor
  - Mechanical factor
  - Provider/process factor
- Reintubation required: Yes/No
- If yes, time to reintubation:

## Contributing Factors (Free Text)

-

## Immediate Corrective Actions

-

## Required Signatures

- RN name/signature/time:
- RT name/signature/time:
- Provider name/signature/time: