Note: If the event involves patient or customer safety and/or risk, report the event in the Safety Event Management (SEM) system.

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* 1. Employee name providing service recovery:

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* 2. Department in which employee works most:

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* 3. Area where service event occurred:

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* 4. Date of service event:

Date

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* 5. Action taken:

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* 6. Service event description:

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* 7. What could be done to prevent service events like this in the future?

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* 8. Resolution status:

T