SERVICE PROVIDER INCIDENT REPORT

Instruction: This form must be completed in its entirety. Additional information may be attached to supplement information provided on the report form. Please call the member’s IDT within 24 hours of an incident.

Date Form Completed:

Person Completing Form Information

Name:
Title:
Agency: / Telephone Number:

Case Manager Information

Name: / Case Manager called
Yes / No
Member Information
Name: / Gender / Birth Date
Male / Female
Guardian Name: / NA / Contacted
Yes / No
Event
Date of Event: / Location Event Occurred (Street, City, State, Zip Code)
Type of Setting

Residence

/

Other

Participant’s private home or apartment / Work / day program
Adult family home (1-2 beds) / Community work site
Adult family home (3-4 beds) / Community setting; e.g., park, store, etc.
CBRF / Transport
Children’s foster home / Another person’s residence
Other- specify:
Name of Provider Agency:
Address of Provider Agency:
How did the reporter learn of this event?
Type Of Injury
Abrasion / Burns / Fracture / Dislocation / Sharp Injury
Aggravation Of Pre-Existing Condition / Chemical / Head Injury / Skin Tear
Allergic Reaction / Contusion / Bruise / Laceration / Sprain / Strain
Back Injury / Expired / Puncture / No Apparent Injury / Effect
Broken Tooth / Teeth / Exposed To B/B Fluids / Rash / Not Applicable
Bump / Struck / Exposure To TB / Scratch / Other
Body Parts Effected: / Indicate with a “X” location on body diagram

Abdomen / Elbow / Internal Organs
Ankle / Face / Knee
Arm / Finger / Leg
Back / Foot / Neck
Buttocks / Groin / Shoulder
Chest / Hand / Throat
Ear / Head / Toe
Eye / Hip / Trunk
Wrist
Physician Contacted / Physician’s Name:
Yes / No
Severity of Injury / Illness at Time Of Report
No Injury / Illness – Level 0 / Major deterioration of functional status requiring medical intervention – Level 2
Minor (Temporary / No Complication, e.g. abrasion) – Level 1 / Death directly attributed to this occurrence – Level 3

Page 2

Event type / Allegation / Only / Event type / Allegation / Only

Abuse

/

Neglect

Mental / Emotional / Environmental
Physical / Fail to follow plan / poor care
Sexual / Medical / failure to seek
Verbal / Nutrition
Self-neglect

Death

/ Unanticipated absence of provider
Accidental
Related to psychotropic medication* /

Residence Damage

Related to restraint* / Fire
Related to suicide* / Other
Note: Deaths related to above fraction in certain facilities must be reported to the Department / DSL Death Review Committee within 24 hours / Weather

Other

Serious illness / injury / accident
Significant behavior that place others at risk

Hospitalization

/ Suicide attempt
Emergency medical / Other rights violation
Mental health / behavior / Unanticipated absence of participant

Law Authority Contact

Commission of crime
Victim of crime / BQA’s form DSL-2447 completed? / Yes / No

Misappropriation

Person’s funds
Person’s property
INVESTIGATION SUMMARY
Provide a summary of the event or allegation and the corresponding investigation including all witness statements and any relevant documentation. Attach additional pages if necessary.

Signature: ______Title: ______Date: ______

SERVICE PROVIDER INCIDENT REPORT