There are lots of great articles on the internet about this and some include their forms.
This article has a form similar to ours.
Respiratory Therapy will usually fill out the form but both RT and nursing will investigate to see if anything could have been done differently. We focus on getting the prehospital tubes or those from other facilities resecured quickly by our taping methods or tube holders so that both RNs and RTs are familiar with them. Security of the tube, restraints and sedation are assessed with each patient/ventilator check. Whether the RT was present in the ICU is also a factor and if they were closeby when beds were changed or other movements where the patient may have been unrestrained or in a position that required close monitoring.
The RC journal is also a great source.