1550 HUMBOLDT AVENUE
WEST ST. PAUL, MN 55118-3411
(651)450-1802 FAX: (651)450-7923
INCIDENT REPORT
(NON-VULNERABLE)CLIENT: / DATE:
DATE OF INCIDENT: / TIME OF INCIDENT: / AM / PM
LOCATION OF INCIDENT:
OTHER CLIENT(S) INVOLVED:
(Refer to other clients as client #2, #3, etc.)
STAFF INVOLVED:
(NAME/TITLE)
OTHERS INVOLVED:
(NAME/RELATIONSHIP)
TAI PROGRAM NAME:
Incident Type (check which type):
Note: All incidents must be reported immediately to the program supervisor when an incident occurs or after becoming aware of an incident. Incidents are as defined in TAI’s Incident Response and Reporting policy.
Serious Injury of a client / Sexual Activity between clients involving force or coercion
Client medical emergency, unexpected serious illness, or significant unexpected changes in an illness or medical condition of a client that requires the program to call 911, physician treatment, or hospitalization / Conduct by a client against another client that is so severe, pervasive or objectively offensive that it substantially interferes with a person’s opportunities to participate in or receive service or support, places a person in actual and reasonable fear of harm, places the person in actual and reasonable fear of damage to property of the person or substantially disrupts the orderly operation of the program
Any mental health crisis that requires the program tocall 911, a mental health crisis intervention team or a similar mental response team or service when available and appropriate
An act or situation involving a client that requires
program to call 911, law enforcement or the fire
department / Client unauthorized or unexplainedabsence
Death of a client
Describe Incident, Staff Response and Resolution of incident, including treatment given and client response (use additional sheets if necessary):
Signature of Reporter / Position/Title
Internal Review, comments and corrective actions/written recommendations or service delivery changes
For Incidents involving Death or Serious Injury, Please Complete the Following:
Were related policies and procedures followed by staff? / YES / NO
If No, provide comments:
Were the related policies and procedures adequate? / YES / NO
If No, provide comments:
Is there a need for additional staff training? / YES / NO
If Yes, provide comments:
For All Incidents, Please Complete the following:
Is the incident similar to past events with the person, or the services involved? / YES / NO
If Yes, provide comments:
Is there a need for corrective action to protect the health and safety of the persons receiving services and to reduce further occurrences? / YES / NO
If Yes, provide comments:
Summary of Review, recommendations, and action plan to protect health and safety and minimize the risk of harm to the person, and (if needed) to correct current and prevent future lapses in service:
Signature/Title / Date
Signature of Designated Coordinator/QIDP review and approval / Date
EXTERNAL REPORTING OF INCIDENT
(Shaded area must be completed within 24-hours of Incident)Date of verbal Notification
(24 hours) / Notification Made By / **Date Incident Report Sent
Legal Representativeor designated emergency contact
Case Manager
Program Director
Other
Other
*Ombudsman / Date Ombudsman form faxed: / N/A
*DHS / Date DHS form faxed: / N/A
* Ombudsman and MN Department of Human Services notified for deaths and serious injury only
**Incident report must be sent per the timelines stipulated in the client’s CSSP. If no timeline indicated, it is to be sent no later than 14 calendar days after the date of the incident.
Additional Comments:
SR/1021-816