Auglaize DD Incident Form

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Please fill out this form completely. For possible MUIs involving Law Enforcement, Unanticipated Hospitalization, and Unapproved Behavioral Support, an administrative review form should be submitted in addition to this incident report.

Email *

Provider Name & Address: *

Provider's Phone Number: *

Individual's Name: *

Individual's Date of Birth: *

YYYY

Individual's Address: *

Date of Incident: *

YYYY

Time of Incident: *

Time

Location of Incident (eg: at home, at work, at the mall, etc.): *

Description of Incident (Who, What, Where, When):
*

Injury (Describe Type and Location):
*

Body Part Injured: *

Head or Face

Mouth/Teeth

Hands/Arms

Feet/Legs

Neck or Chest

Abdomen

Back/Buttocks

Genitals

No Injury.

Required

Immediate Action to Ensure Health and Welfare of Individual(s):
*

Name of Primary Person(s) involved (PPIs):
*

Relationship to Individual:
*

Witnesses to Individual:
*

Others Involved: *

Type of Notification:

NOTE: Please choose who else you have notified about this incident.

Guardian/Advocate

SSA (Required for Independent Providers)

Licensed or Certified Provider

Staff of family living at individual's home and responsible for their care

Law Enforcement (Name, Badge Number, Jurisdiction and contact information required for Law Enforcement)

Children Protection Services Agency (name and contact information required for Children Services)

County Board

Administrator (Required for ICF)

Support Broker (if applicable)

Required

Name/Title and Date/Time of all persons notified:
*

Reporter's Name and Phone Number:
*

Date Reporter Discovered the Incident:
*

YYYY

Time Reporter Discovered the Incident:
*

Time

Was Further Medical Follow-Up Provided? (If yes, please explain):
*

Was Additional Administrative Action Given? (If yes, please explain):
*

Causes and Contributing Factors:
*

Preventative Measures:
*

Signature (By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.)
*

Submit

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