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This is a very serious form. Hopefully you won't need to use this form often. You will use it to report any incident or unusual incident. For example you have a 3 year old who needs stitches from falling off a bike or a child is cut when he put his hand through a window. On this form you state what happened, when it happened, where it happened, who was there, what you did to remedy the situation. View this form in full page view. This form is for informational purposes only. Get official copy from your Case Worker. After any incident discuss possible ways of preventing a similiar incident from happening again. Ask yourself the question - What changes could I make to minimize or eliminate future reoccurrences.
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Date of Report:Time:
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Name of Client: Provider Name:
____________________________________________
Address:
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City: State: Zip
Code:
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PhonePhone:
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BSU number:County where facility is located:
____________________________________________
Date of Birth:Sex:Date of Admission:
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Level of Mental Retardation:Date of Incident:Time:
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Location of Incident: (bathroom, Hall, etc.)Facility / Agency License
Number:
Describe in detail exactly what happened and any circumstances which
may have precipitated the Incident / Unusual Incident:
(Attach additional sheets if necessary)
_____________________________________________
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_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
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Physician's name and statement (if applicable) - Include treatment and
follow-up action:
_____________________________________________
Action taken:
_____________________________________________
Other pertinent Information (seizures, visual imparements, safety
conditions, etc.):
_____________________________________________
Relative or guardian
notified: Relationship: Address: Phone:
_____________________________________________
Typed/printed name and signature of person reporting:Title:Phone:
Date mailed to:
------------ Regional office of Mental Retardation_____________ Office
of Children, Youth & Families
_______ County Mental Retardation office_____________ Department of
Health
_______ Funding agency (specify) ______________________
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