DODD – Possible or Determined MUI Report Form

DODD – Possible or Determined MUI 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 (W ho, What, Where, When)
Injury – Describe Type & Location
Immediate Action to Ensure Health & Welfare of Individuals
Name of PPI(s)
Relationship to Individual
Witnesses to Incident
Others Involved
TYPE OF NOTIFICATION
Guardian / Advocate/Family
Date/Time
SSA
Date/Time
Licensed or Certified Provider
Date/Time
Staff or Family living at the Individual’s home
Date/Time
LE (Name, Badge Number, Jurisdiction, Contact Info)
Date/Time
Children’s Services (if applicable)
Date/Time
County Board
Date/Time
Administrator (Required for ICF)
Date/Time
Senior Management
Date/Time
Other Providers of Service
Date/Time
Additional Information/or Administrative Follow-Up:
A.Further Medical Follow-up
B.Administrative Action
Printed Name
Signature
Title
Date

MonthDayYear
Date
Body Part Injured

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

AnteriorCheck All Areas InjuredPosteriorDetailed description of area(s) injured:Date:Title:Body Part InjuredPrinted Name:Signature:Additional Information/or Administrative Follow-Up:B.Administrative Action:A.Further Medical Follow-up:AnteriorAnteriorAnteriorAnteriorAnteriorPosteriorPosteriorPosteriorPosteriorPosteriorAnteriorAnteriorPosteriorPosterior
Anterior

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

DatePreventive measures: (For Provider’s internal use)
Administrator Review
Date

MonthDayYear
Date
DODD MUI UNIT INCIDENT REPORT DECEMBER 2019
Should be Empty: