Ibogaine Incident or Grievance Report Form

Ibogaine Incident/Grievance Report Form

The Ibogaine Report Form Project is being implemented to improve ibogaine therapy by providing a process for reporting information of adverse medical events, safety issues and other incidents that may impact on ibogaine treatment and care. The form enables patients and providers alike to report any incident whether negligible or life threatening. Data of a medical nature will be shared with all ibogaine providers to help assure the safety of persons treated with ibogaine. Information that is shared will not include the identity of patients or providers. An incident report may be filed by a provider, a patient or any treatment team member.

This form may also be used to file a grievance. However, grievance reports may only be filed by patients. Discussion of grievance reports will only take place between the Dora Weiner Foundation and the parties involved. Should you wish us to contact the ibogaine provider on your behalf we will require you to sign a medical information release form. Patients have the right to file a grievance report in accordance with the Ibogaine Patients' Bill of Rights.

In order to validate an incident or grievance report you will have to identity yourself and provide other contact information.

Confidentiality

All information that you provide will be held strictly confidential in the same manner as the patient protections described in the US Federal Confidentiality Regulations 42 CFR and the Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule) as established by the Department of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, data from reports that does not identify you may be used in research or publication.

Validation

All reports must be validated. All persons submitting reports will be contacted as part of the validation process. If you do not receive a response to your report within ten business days please call us at 1 718 442-2754 or email us at the address below. If you call please indicate you are calling to discuss a Report issue.

Should you have any questions or need assistance in filling out this form, contact the Dora Weiner Foundation

When you have completed the form click on the Submit button at the bottom of the page.

* (Indicates required information) We strongly urge you to answer all questions as not doing so may delay the processing of this form..

Contact information/report submitter

* 1. Today's date(dd/mm/yy)

* 2. Last name *3. First name

* 4. Street address

* 5. City 6. State

7. Province * 8. Country

*9. Zip/postal code *10. Phone #

11. Fax # *12. Email

For 13 - 16 please a make selection. If 16 is selected, please provide information in 17.

*13. I am a patient *14. I am a staff member *15. I am a treatment provider *16. Other

17. If "Other" please indicate relationship

Nature of report: (select one) 18. Medical Incident 19. Patient Grievance

Contact information/Ibogaine Provider:

20. Last Name 21. First Name

* 22. Name of clinic/facility

23. Clinic/facility/POB/ street address

* 24. City 25. State

26. Provence * 27. Country

* 28. Zip/postal code * 29. Phone #

30. Fax # * 31. Email

* 32. Please describe the incident/grievance in detail:

If this is a medical incident report, please include age, sex, weight, dose of ibogaine and medical history of patient. Please provide date(s) of incident or grievance. Thank you.

33. Comments:

Click to send information

The DWF site is a historical archive. With the exception of this message no content has been altered or changed in any manner. Many links will no longer work, most email addresses and phone numbers are outdated (unless you have access to a time machine that connects with the 2000s). For a present-day organization based upon similar concepts (circa 2015) you may want to try visiting GITA.