Disability Development Resources, LLC
Providing… Direction. a Difference. Results.
INCIDENT REPORT
Date ______Time: ______am./p.m.
NOTIFICATION (as applicable):
Director: ______Date: ______Time: ___:____ a.m./p.m. ______
Guardian: ______Date: ______Time: ___:____ a.m./p.m. ______
Other: ______Date: ______Time: ___:____ a.m./p.m. ______
DDD REPRESENTATIVE CONTACTED (as applicable):
Support Coordinator: ______Date: ______Time: ___:____ a.m./p.m. ______
Other: ______Date: ______Time: ___:____ a.m./p.m. ______
SPECIFIC AUTHORITIES NOTIFIED (as applicable):
Adult Protective Services:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
Child Protective Services:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
Police:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
Fire/Paramedic:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
Dept. of Health Services:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
County Health Dept.:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
Doctor/Pharmacy/Medical Facility:
Name: ______Title: ______Date: ______Time: ___:____ a.m./p.m. ______
DESCRIPTION OF INCIDENT: Give a statement of the FACTS leading up to and including the event. Include the initials of all others involved. If a mark/injury is present, use the body chart (see next page) to indicate type and location of mark.
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IN CASES WHERE THERE IS A PHYSICAL MARK OR INJURY, PLEASE USE AN ARROW TO NOTE THE LOCATION ON THE FIGURES BELOW.
LOCATION/TYPE OF MARK/INJURY
(if applicable)
q CUT
q BITE
q SCRATCH/SCRAPE
q BRUISE
q BURN
q REDDENED AREA
q OTHER: ______
______
Was an Emergency Measure needed (CIT)? q Yes q No q N/A
If yes, describe action taken: ______
______
______
Reporter’s Name/Title (Print): ______
Reporter’s Signature: ______
Date: ______
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CONSUMER BEHAVIOR/FINDINGS: q Yes q No (If yes, complete this section)
Was there an identified antecedent? q Yes q No q N/A
List: ______
______
Is this a typical behavior for the Consumer? q Yes q No q N/A
Were appropriate interventions used? q Yes q No q N/A
List: ______
______
Did inappropriate DSP/family/other behavior contribute to this incident?
q Yes q No q N/A
How: ______
______
Were the Consumer’s rights upheld? q Yes q No q N/A
If not, what was violated: ______
______
Was the Consumer treated with dignity and respect? q Yes q No q N/A
If not, how: ______
______
Was the incident a result of a possible medication side effect/adverse reaction/medical condition? q Yes q No q N/A
If so, list: ______
______
Did the DSP receive appropriate training/supervision? q Yes q No q N/A
If so, list: ______
______
Did an environmental condition contribute to this incident? q Yes q No q N/A
If so, how: ______
______
Other/comments: ______
______
Is a corrective action plan required? q Yes q No q N/A
If so, explain: ______
______
INCIDENTS/ACCIDENTS/INJURIES to DSP/FAMILY/OTHERS (all other findings):
Was the incident a result of DSP/family/others’ behavior? q Yes q No q N/A
If so, how: ______
______
Was the incident a result of a medical condition? q Yes q No q N/A
If so, how: ______
______
Was the incident a result of an environmental condition? q Yes q No q N/A
If so, how: ______
______
Was the incident a result of a Consumer behavior? q Yes q No q N/A
If so, how: ______
______
Was a vehicle accident report for insurance completed? q Yes q No q N/A
Is a corrective action plan required? q Yes q No q N/A
If so, explain: ______
______
INCIDENT MANAGEMENT LIASION’S REVIEW/COMMENTS:
______
______
______
SIGNATURE: ______DATE: ______
DIRECTOR’S REVIEW/COMMENTS:
______
______
______
SIGNATURE: ______DATE: ______
COPY TO (as applicable):
q Site: ______DATE: ______
q Consumer/Responsible Person: ______DATE: ______
q Support Coordinator: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
q Other: ______DATE: ______
DSP036A 6/10 2/5