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Forms and Data Elements image

The following ICE documents can be accessed for printing or downloading by clicking the links at left. Acrobat Reader is required to view the documents. Click here to download Acrobat Reader: Download Acrobat Reader

ICE Reporting Form
This form records patient demographics and outcomes data for extravasations. One form should be completed for each incident.

ICE Reporting Form with Patient Identifiers
This alternate version of the ICE Reporting Form includes patient identifiers. Participants may choose to record data on this paper form for internal tracking purposes. However, patient identifiers are not entered into the ICE database due to HIPAA considerations.

Data Dictionary
This document provides definitions of data elements used in the ICE Reporting Form.

Adverse Event Report Template
This document is a template for creating adverse event reports, suggested for use in writing SOAP notes.

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© American College of Radiology
Version: 13.12.20202