I. Identifying Information

Incident Primary Category: Click for Choices:AltercationClient DeathClient Injury or IllnessElopementSexual BatterySuicide AttemptOther Incident
Does this fit criteria telephone notice to HQ within two hours? (unexpected client death, adverse departmental impact/and or endangerment of clients) Click for ChoicesYesNO
Is there likely to be media interest in this incident? Click for choicesYesNo
Incident Date:
Time of Incident:
Region: /

District 3

County: Click for Choices:AlachuaBradfordColumbiaDixieGilchristHamiltonLafayetteLevyPutnamSuwanneeUnion
FAHIS#:
Program Area: Click for Choices:AdministrationAdult ServicesDevelopmental DisabilitiesEconomic Self-SufficiencyFamily Safety - CPIFamily Safety ARSFamily Safety - FC/PSMental HealthSubstance AbuseOther: Explain If Other, Explain:
Victim/Person Involved:
Victim/Person Type: Click for Choices:ChildAdult
Victim/Person Group: Click for Choices:ClientEmployeeOther
Contract Provider Name/Foster Home:
Location/address of Incident:
Type of Facility:
Victim’s Primary Residence is Florida? Click for Choices:YesNoDon't Know
Reviewed By:
Incident Coordinator: /

Tom Barnes

Incident Reporter:

Report Entered by:

IR Telephone #:

Description Summary:

II. Participant(s) Witness(es) (if applicable)

Full Name / Birth Date / Age / Race / Gender / Type of Witness
BlackWhiteHispanicAsianOther / MaleFemale / VictimClientEmployeeParticipantWitness
BlackWhiteHispanicAsianOther / MaleFemale / VictimClientEmployeeParticipantWitness
BlackWhiteHispanicAsianOther / MaleFemale / VictimClientEmployeeParticipantWitness
BlackWhiteHispanicAsianOther / MaleFemale / VictimClientEmployeeParticipantWitness
BlackWhiteHispanicAsianOther / MaleFemale / VictimClientEmployeeParticipantWitness

III. Description of Incident

Give Detailed Account – (Who, What, When, Where, Why, How)

IV. Corrective Action and Follow Up

Immediate Corrective Action:
Is follow up action needed? Click for Choices:YesNo
If Yes, Please Specify:

V. Individuals Automatically Notified

VI. Individuals Notified

Abuse Registry

/

Health Care Admin

/

Law Enforcement

Name:
Badge/ID#:
Date:
Time:
Called: / Time: / Time: / Time:
Copy: / Time: / Time: / Time:
Accepted:

Parent/Guardian/Family Member

/

Other:

(Please Specify) /

Other:

(Please Specify)
Name:
Date:
Time:
Called: / Time: / Time: / Time:
Copy: / Time: / Time: / Time:

VII. Death Review Information

Date of Death:

/

Time of Death:

Place of Death:

Suspected Cause of Death:

Classification of Death: Click for Choices:AccidentHomicideNatural (expected)Natural (unexpected)Suicide;

/

Explain:

Death Review Summary

Description of events leading to death and include previous department involvement:

Did death occur in restraint/seclusion?:

Medical Examiner Case?:

Autopsy Requested?:

Date Requested:

Autopsy Done:

Date of Autopsy:

District 3 Incident Reporting Form Page 1 of 3F-RM-1004

10/02/18