Incident Report
All incidents must be reported within 24 hours of the incident or within 24 hours of when the program became aware of the incident. A separate form must be completed for each person – do not use identifying information, such as names or initials, if the incident involved another person receiving services.
Date of incident
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Month
/
Day
Year
Date
Time of incident
Location of incident
Person name
Program Name ( IHS with Training, IHS with Family Training, 24 Hour EA)
Incident Type
(check
all that apply
):
Health and Developmental Disabilities
Death or serious Injury Must also be reported using the forms from the Office of Ombudsman for Mental Health and Developmental Disabilities: - Fractures; Dislocations; Evidence of internal injuries; Head injuries with loss of consciousness or potential for a closed head injury or concussion without loss of consciousness requiring a medical assessment by a health care professional, whether or not further medical attention was sought; Lacerations involving injuries to tendons or organs and those for which complications are present; Extensive second-degree or third-degree burns and other burns for which complications are present; Extensive second-degree or third-degree frostbite, and other frostbite for which complications are present; Irreversible mobility or avulsion of teeth; Injuries to the eyeball; Ingestion of foreign substances and objects that are harmful; Near drowning; Heat exhaustion or sunstroke; Attempted suicide; and All other injuries and incidents considered serious after an assessment by a health care professional, including but not limited to self-injurious behavior, a medication error requiring medical treatment, a suspected delay of medical treatment, a complication of a previous injury, or a complication of medical treatment for an injury.
Any medical emergency, unexpected serious illness, or significant unexpected change in an illness or medical condition that requires the program to call 911, physician, advanced practice registered nurse, or physician assistant treatment, or hospitalization
Any mental health crisis that requires the program to call 911 or a mental health crisis intervention team
An act or situation involving a person that requires the program to call 911, law enforcement, or the fire
Unauthorized or unexplained absence from a program
Conduct by a person against another person 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 the person in actual and reasonable fear of harm; places the person in actual and reasonable fear places the 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 sexual activity between persons that involves force or coercion.
Any emergency use of manual restraint (Also refer to Emergency Use of Manual Restraint Policy)
A report of alleged or suspected child or vulnerable adult maltreatment Also refer to (Maltreatment of Minors or Vulnerable Adults Reporting Policy)
OTHER
Description of incident
Description of staff response to the incident
Applicable support plan addendum(s) was implemented for the person(s) involved.
Applicable support plan addendum(s) was implemented for the person(s) involved.
Applicable program policies and procedures were implemented as written.
Staff person(s) who responded to the incident
Name and signature of reporting staff
Date
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Month
/
Day
Year
Date
Submit
Should be Empty: