DODD – Unusual Incident Report Form
Provider Name & Address
Individual’s Name:
DOB:
Address
Address
Street Address Line 2
City/County
State / Province
Postal / Zip Code
Date of Incident:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident:
Time of Incident:
AM
PM
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)
Please Select
Guardian/Advocate/Family
Service Coordinator
Licensed or Certified Provider
Staff or Family Living at the Individuals Home
Administrator
Who was notified? (Select Multiple, If applies)
Guardian / Advocate/Family
SSA
Licensed or Certified Provider
Staff or Family living at the Individual’s home
LE (Name, Badge Number, Jurisdiction, Contact Info)
Children’s Services (if applicable)
County Board
Administrator (Required for ICF)
Senior Management
Other Providers of Service
Guardian / Advocate/Family
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
SSA
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Licensed or Certified Provider
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Staff or Family living at the Individual’s home
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
LE
Name, Badge Number, Jurisdiction, Contact Info
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Children’s Services (if applicable)
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
County Board
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Administrator (Required for ICF)
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Senior Management
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Other Providers of Service
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Addition
al
Inform
at
i
on/
or
Administr
at
ive Follow-
Up:
A.Further Medical Follow-up:
Printed Name:
*
Signature
Title:
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Body Part Injured:
Head or Face
Neck or Chest
Mouth / Teeth
Abdomen
Hands/Arms
Back/Buttocks
Feet/Legs
Genitals
Anterior
Right
Left
Left
Right
Detailed description of area(s) injured:
Causes and Contributing Factors:
Preventive measures: (For Provider’s internal use)
Signature
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: