(* = Mandatory Field)                                                                                                                                                         v06212013

Note, if incident involves one individual, an Individual Incident Report needs to be completed instead.

Initial Report: Filing Agency Information
*(1) Filing Agency: 																									
*(2) Staff filling out Paper Incident Report: 																			
  (3) Staff Responsible for Incident Follow-up: 																		

Initial Report: Incident Classification
*(4A) Date Incident Discovered: 		   			  *(4B) Approximate Time Incident Discovered: 				
                                 MM/DD/YYYY				                                   					  HH:MM AM/PM
*(5) Do you know the date and/or approximate time that the incident occurred?  
Check one  Both    Date Only    Time Only    Neither
Complete only if known 
(5A) Date Incident Occurred: 					(5B) Approximate Time Incident Occurred: 				
								    MM/DD/YYYY			  		 		       					    	   HH:MM AM/PM
*(6) Did staff directly observe the incident?    Yes 	 No 	 Unknown
*(7) Who was responsible for the supervision of the individuals at the time of the incident?
	    Choose one from the following:
       	 Individuals  			 Other Provider 
 Family				 Other
 Reporting Provider		 Unknown

(8) If Reporting Provider, was supervision at the time of the incident being provided as assigned? 
    Yes 	 No 	 Unknown
(9)  Responsible Site: 																								
(10)  Area Office with Primary Responsibility for the site: 														

(1) Fire			            	            
	 Known Origin – Allegedly Started by Individual		 
  	 Known Origin – Not Started by Individual					 Source Unknown
	  
(2) Suspected Mistreatment	
	 Alleged Omission – Failure to Provide Needed Supports
	 Alleged Omission – Failure to Provide Needed Supervision

 (3) Theft  
	 Alleged Victim
	 
(4) Transportation Accident  	
	 Motor Vehicle   
	 Other
	 
(5)    Emergency Relocation

(6)    Other  

*(11) Site-Level Incident Categories: Check one 

*(12A) Did the incident involve the ingestion of non-food substances?   			 Yes      No	 Unknown
*(12B) Did the incident involve unauthorized use of drugs/alcohol?                    	 Yes      No	
*(12C) Did the incident involve suicidal threat/ideation?                                     	 Yes      No	
*(12D) Did the incident involve non-compliance with a medical directive?        	 Yes      No	
*(12E) Did the incident involve a medication refusal?       							 Yes      No	

* Is there an Injury?    No     
If You Answer This Question “Yes”, You Need To File an Individual Incident Report, Not A Site-Level Incident Report

Initial Report: Incident Description I
*(13) Incident Description:  Describe in detail exactly what happened during the incident. Include dates, times, and all people involved including staff. Include all relevant details prior to, during, and after the incident. 

Initial Report: Incident Description II
*(14) What is the most recent status of the individuals? 																

*(15) Is the Incident Location known?   Yes     No
(15A) Where did the incident occur? Check one
•	
•	Individuals’ Residence
•	Family Residence
•	Residential Setting-Other
•	Respite
•	Day Service
•	Work Site
•	School
•	Community
•	Vehicle
•	Other
•	Unknown

(15B) Location Detail: Check one
•	
•	Bedroom
•	Dining Area
•	Living Area
•	Kitchen
•	Bathroom
•	Common Area
•	Public Area
•	Laundry Area
•	Stairs or Stairwells
•	Basement
•	Yard
•	Work Area
•	Vehicle
•	Outdoor Area
•	Other

(15C) Site Location of Incident (address):  																		

(15D) If not at provider site, information about incident location:
 Location Name/Description: 																				
 Location Name and address, if any: 																		

Initial Report: Actions Taken To Protect Health, Safety, and Rights
*(16) Actions Taken to Protect Health, Safety and Rights: Immediate actions taken to protect the individuals.  Describe administrative, health/safety, treatment and other actions taken to address the incident to date.
																																																																																										
(17) Treatment Provided By:  Check all that apply
•	
•	Staff (non licensed)
•	LPN, RN, NP
•	PCA
•	Other (describe above)
•	None

Initial Report: Involved Parties
*(18) People Involved with Incident: (Add additional sheets as needed)
		*(18B) Involvement
Select all that apply	*(18C) Relationship
Select all that apply	
(18A) Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

(18D) Telephone: 
                   (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		

Initial Report: Notification
*(19A) Was the On-Call person notified?	 Yes	 No	
*(19B) Name of On-Call person:  							

*(20A) Has Executive Office of Elder Affairs been notified? (Only applies to individuals greater than 59 years old.  Choose ‘N/A’ for all other individuals.)  Yes-Have Notified  	 No-Will Notify  	 No             N/A
*(20B) Has DPPC Been Notified?         	  Yes-Have Notified  	 No-Will Notify  	 No
*(20C) Has DCF Been Notified?          	  Yes-Have Notified  	 No-Will Notify  	 No             N/A
  (21) Has Family/Guardians Been Notified?   Yes-Have Notified  	 No-Will Notify  	 No 	 N/A
*(22) Was Law Enforcement Involved?	  Yes	 No	 Unknown
*(23A) Signature of the Staff filling out Paper Incident Report: 														
*(23B) Position:  																										
*(23C) Telephone: (	       )	      -			 *(23D) Date/Time of Report:  				    				     
              							      				    								       MM/DD/YYYY	       HH:MM AM/PM    
*(24A) Name of Supervisor:  																							 
*(24B) Position:  																										
*(24C) Signature of Supervisor:  																						
  (24D) Telephone:   (           )         -			 (24E) Date/Time of Review: 				  				
										  	  									     MM/DD/YYYY	     HH:MM AM/PM    

Final Report: Additional Information
*(25) Incident Description:  Any updated or corrected information from the Incident Description (Question 13) including dates, times, people involved, and relevant details prior to, during, and after the incident. Indicate the current status of the individuals. If law enforcement has been contacted please list details of actions taken by law enforcement. 
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Final Report: Action Steps
*(26) Are there Additional Action Steps for this Incident:   Yes 		 No		 Unknown
(26A) Action Step:	(26B) Targeted Completion Date: (MM/DD/YYYY)	(26C) Responsible Party:
 (Name and/or Position)	

			

Final Report: Involved Parties
(27) People Involved with Incident: 
Correct only if there are changes from the Initial Report.  Add additional sheets as needed
		*(27B) Involvement
Select all that apply	*(27C) Relationship
Select all that apply	
(27A) Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

(27D) Telephone: 
                   (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		
Involved Party Name:	•	Eyewitness to Incident
•	Person who filled out paper report
•	Person who reported Incident
•	Provider/DDS Staff who discovered/first made aware of incident	
•	Reporting Provider Staff  	Relative
•	Non-Reporting Provider 	Volunteer
Staff					General Public
•	Individual/Consumer		Other
•	Friend

Telephone: (         )           -		•		

Final Report: Verification of Time and Categorization
*(28) Initial Report Information is correct to the best of my knowledge:
    Yes, If Yes, Skip to # 40A.
    No, If No, describe any Updated or Corrected Information below and answer all applicable questions: 
*(29A) Date Incident Discovered:  				 *(29B) Approximate Time Incident Discovered: 					                       					    MM/DD/YYYY				                                         				    HH:MM AM/PM
*(30) Do you know the date and/or approximate time that the incident occurred: 
 Both        Date Only      Time Only       Neither
 (30A) Date Incident Occurred:  				 (30B) Approximate Time Incident Occurred: 											                MM/DD/YYYY				                                           			      HH:MM AM/PM

 (3) Theft  
	 Alleged Victim
	
 (4) Transportation Accident  	 
	 Pedestrian  
	 Motor Vehicle   
	 Other
	 
(5)    Emergency Relocation
 
(6)    Other  

(1) Fire			            	            
	 Known Origin – Allegedly Started by Individual		 
  	 Known Origin – Not Started by Individual					 Source Unknown
	  
(2) Suspected Mistreatment	
	 Alleged Omission – Failure to Provide Needed Supports
	 Alleged Omission – Failure to Provide Needed Supervision	

*(31) Site-Level Incident Categories: Check one 

*(32A) Did the incident involve the ingestion of non-food substances?   			 Yes      No	 Unknown
*(32B) Did the incident involve unauthorized use of drugs/alcohol?                    	 Yes      No	
*(32C) Did the incident involve suicidal threat/ideation?                                     	 Yes      No	
*(32D) Did the incident involve non-compliance with a medical directive?        	 Yes      No	
*(32E) Did the incident involve a medication refusal?       							 Yes      No	
* Is there an Injury?    No     
If You Answer This Question “Yes”, You Need To File an Individual Incident Report, Not A Site-Level Incident Report

*(33) Staff filling out Paper Final Report: 																			
*(34) Did staff directly observe the incident?    Yes    No     Unknown
*(35) Who was responsible for the supervision of the individuals at the time of the incident?
	    Choose one from the following:
       	 Individuals					 Other Provider 
 Family						 Other
 Reporting Provider				 Unknown
  (36) If Reporting Provider, was supervision at the time of the incident being provided as assigned? 
            Yes    No
*(37A) Was the On-Call person notified?	 Yes	 No	
*(37B) Name of On-Call person:  							

*(38A) Has Executive Office of Elder Affairs been notified? (Only applies to individuals greater than 59 years old.  Choose ‘N/A’ for all other individuals.)  Yes-Have Notified  	 No-Will Notify  	 No             N/A
*(38B) Has DPPC Been Notified?          	 Yes-Have Notified  	 No-Will Notify  	 No
*(38C) Has DCF Been Notified?         	  Yes-Have Notified  	 No-Will Notify  	 No             N/A
  
(39) Has Family/Guardians Been Notified?   Yes-Have Notified  	 No-Will Notify  	 No 	 N/A
*(40) Was Law Enforcement Involved?	  Yes	 No 	 Unknown

Final Report - Finalization
*(41A) Name of Person Finalizing Report: 																			
*(41B) Position: 																
*(41C) Signature: 																										
  (41D) Telephone:   (           )         -			 (40E) Date/Time of Review: 				  				
										  	  									     MM/DD/YYYY	     HH:MM AM/PM