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JL Family Care Services LLC — Incident Report
In an emergency, call 911 first. Complete this form as soon as possible, no later than 24 hours after the incident. Use the member reference code only. Do NOT type Social Security, UCI or any ID numbers.
Person reporting
Your full name
*
First Name
Last Name
Your role
*
Parent-Provider
Staff
Office/Admin
Other
Your phone
*
-
Area Code
Phone Number
Your email
*
Incident
Member reference code
*
Date of incident
*
-
Month
-
Day
Year
Date Picker Icon
Time of incident
*
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2
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4
5
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8
9
10
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:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Where did it happen?
*
Type of incident (check all that apply)
*
Injury that needed medical treatment
Illness that needed medical treatment
Emergency room visit or hospital admission
Missing member
Suspected abuse
Suspected neglect
Medication error
Law enforcement contact
Member was a victim of a crime
Behavior incident
Property damage
Death
Other
What happened? Describe what happened before, during and after.
*
What did you do right away?
*
Was 911 called?
*
Yes
No
Did the member receive medical treatment?
*
Yes
No
Unknown
Witnesses (names and how to reach them)
Upload photos or documents (optional)
Upload a File
Cancel
of
Notifications
Who has been notified?
*
Parent or guardian
JL Family Care Services LLC office
IRC service coordinator
Law enforcement
Adult or Child Protective Services
Nobody yet
Other
Date IRC was notified
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Month
-
Day
Year
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Time IRC was notified
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2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Follow-up needed
Certification
Certification
*
I certify that this report is true and complete to the best of my knowledge.
Signature
*
Date signed
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: