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Appendix A14

Pro forma referrals form

Royal United Hospital, Bath, Clinical Ethics Committee

Proforma for Clinical Ethics Committee Records
Note these records are being kept solely for the purpose of statistical recording and audit of the committee’s work

Name of Committee Member
Date and time of contact(s):
Source of Enquiry: (e.g. doctor (grade), nurse (grade), other health professional (position, grade), patient, relative)
Relationship of enquirer to patient:
Nature of problem:

(Note enquirer may remain anonymous)

Names of other members of Committee contacted:

If enquiry referred elsewhere (with permission of enquirer) state to whom, and fill in outcome (below), when known

Outcome(s) with date(s):
Was enquirer happy with outcome?:
Other comments:

Please make 2 copies of this form, one to be retained by you and one forwarded to Chair of the Committee

Copyright of Appendix A14 is held by Royal United Hospital Clinical Ethics Committee

Peter Rudd
Royal United Hospital NHS Trust CEC