DODD – Unusual Incident Report Form

DODD – Unusual Incident Report Form
Provider Name & Address
Individual’s Name:
DOB:
Address

Address

Street Address Line 2

City/CountyState / Province

Postal / Zip Code
Date of Incident:

MonthDayYear
Date
Time of Incident:
Time of Incident:

AMPM
Location of Incident (home in bathroom, at the mall, lunchroom at work):
Description of Incident
Injury - Describe Type & Location
Immediate Action to Ensure Health & Welfare of Individuals
Name of Primary People Involved:
Relationship to Individual:
Witnesses to Incident:
Others Involved:
Who was notified? (Old- Not to be used)
Who was notified? (Select Multiple, If applies)

Guardian / Advocate/FamilySSALicensed or Certified ProviderStaff or Family living at the Individual’s homeLE (Name, Badge Number, Jurisdiction, Contact Info)Children’s Services (if applicable)County BoardAdministrator (Required for ICF)Senior ManagementOther Providers of Service
Guardian / Advocate/Family
Date/Time

MonthDayYear
SSA
Date/Time

MonthDayYear
Licensed or Certified Provider
Date/Time

MonthDayYear
Staff or Family living at the Individual’s home
Date/Time

MonthDayYear
LE
Name, Badge Number, Jurisdiction, Contact Info
Date/Time

MonthDayYear
Children’s Services (if applicable)
Date/Time

MonthDayYear
County Board
Date/Time

MonthDayYear
Administrator (Required for ICF)
Date/Time

MonthDayYear
Senior Management
Date/Time

MonthDayYear
Other Providers of Service
Date/Time

MonthDayYear
Additional Information/or Administrative Follow-Up:
A.Further Medical Follow-up:
Printed Name:*
Signature

Clear
Title:
Date:

MonthDayYear
Date
Body Part Injured:

Head or FaceNeck or ChestMouth / TeethAbdomenHands/ArmsBack/ButtocksFeet/LegsGenitals
Anterior

RightLeftLeftRight
Detailed description of area(s) injured:
Causes and Contributing Factors:
Preventive measures: (For Provider’s internal use)
Signature

Clear
Date:

MonthDayYear
Date
Should be Empty: