Unusual Incident Report Form UNUSUAL INCIDENT REPORT FORM Name of person incident is regarding:(Required) First Last Address where incident occurred:(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date of incident:(Required) is known is unknown Known date of incident:(Required) Time of incident:(Required) Hours : Minutes AM PM AM/PM Discovery date of incident:(Required) Discovery time of incident:(Required) Hours : Minutes AM PM AM/PM Location of incident (Example - home in kitchen, parking lot, lunroom at work, etc.):(Required)Description of incident (Who, what, where, when):(Required)Injury:(Required) Injury No injury Injury (Describe type, location, dimensions, color, etc.):(Required)Upload photos of injury: Drop files here or Select files Max. file size: 256 MB. What immediate action was taken to ensure health & welfare of person(s) involved in incident? (Give specific deatail - Not continue to monitor or notify supervisor):(Required)Name of PPI (Primary Person Involved) causing harm: First Last Relationship of PPI to individual involved in incident:Witness to incident: First Last Witness to incident: First Last Other persons involved and description of how they were involved:Causes and contributing factors (what occurred leading up to the incident):Preventive measures taken at the time of the incident:Type of NotificationsOther is to include Licensed/Certified Provider; Staff/Family Responsible for Care; Law Enforcement, Children Services/Adult Protective Services; Administrator (required for ICF); Support Broker (if applicable); Investigative Agent. Guardian/Advocate SSA/County Board of DD Other Name/Title of Person NotifiedDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time Hours : Minutes AM PM AM/PM Guardian/Advocate SSA/County Board of DD Other Name/Title of Person NotifiedDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time Hours : Minutes AM PM AM/PM Guardian/Advocate SSA/County Board of DD Other Name/Title of Person NotifiedDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time Hours : Minutes AM PM AM/PM Form filled out by:Name of person reporting incident:(Required) First Last Reporter type: Agency/Provider Family Other Other type explanation:Agency (if employed by provider agency):Phone(Required)Email Enter Email Confirm Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
