Free 51677.xls - Indiana

Indiana Division of Disability, Aging and Rehabilitative Services Bureau of Quality Improvement Services Bureau of Developmental Disabilities Services

INCIDENT REPORT - Confidential
For Use in Reporting Circumstances in 431 IAC 1.1-3-1 (b), 460 IAC 6-9-5 and/or BQIS / BDDS Policy and Procedures
Page of

REV. 04-2004

_____________ _____________

To Submit to BQIS / BDDS CENTRAL Office:

E-Mail to [email protected]

OR

FAX to (317) 233-2320

SECTION I - CONSUMER INFORMATION (Subject # 1)
SSN:
ADDRESS DOB SERVICE TYPE: SGL SL HHA HHC HAB./VOC. LP-ICF/MR COUNTY DD WAIVER A&D WAIVER AUTISM WAIVER SUPP SERVICES WAIVER NAME LAST: FIRST:

CITY

ST GENDER NURSING HOME

ZIP M SCHOOL SDC F

CASE MGMT.

SECTION II - ASSOCIATED PERSON (Subject # 2)
This Section is NOT to be Used For Additional Consumers

SSN (Optional):
ADDRESS AGE RELATIONSHIP TO SUBJECT EMPLOYER

NAME

LAST:

FIRST:

CITY

ST GENDER

ZIP M OTHER F

ACQUAINTANCE CLIENT, OTHER CO-WORKER

EMPLOYER FAMILY-GUARDIAN HOUSEMATE

STRANGER STAFF, HAB/VOC STAFF, RESIDENTIAL

SECTION III - REPORTING PERSON and REPORTING AGENCY
NAME LAST: FIRST: POSITION: PHONE #: EXTENSION:

DATE OF REPORT:

REPORTING AGENCY:

E-MAIL OF REPORTING AGENCY:

INDIVIDUAL SUPERVISING AT TIME OF INCIDENT:

RESPONSIBLE SUPERVISORY PROVIDER:

SECTION IV - INCIDENT INFORMATION
INCIDENT DATE: COMMUNITY SGL SDC COMMUNITY JOB HHA HHC NF TIME: COMMUNITY HAB. HOSPITAL FAC. HAB. ADL LP-ICF/MR WORKSHOP OTHER (Explain) HOME, OWN SCHOOL WHERE OCCURRED? HOME, FAMILY

INDICATE WHICH of the FOLLOWING AGENCIES and/or INDIVIDUALS HAVE BEEN INFORMED
APS/CPS? RES. PROVIDER? HAB/VOC PROVIDER? YES YES YES N/A N/A N/A LEGAL GUARDIAN? BDDS SC? (REQUIRED) CASE MANAGER? YES DATE YES YES YES N/A N/A NAME NAME NAME DATE DATE DATE YES N/A DATE

BQIS CENTRAL OFFICE (REQUIRED)

POLICE?

THIS SECTION IS FOR BQIS / BDDS CENTRAL OFFICE USE ONLY
DATE RECEIVED BY BQIS - BDDS: ALL ACTION COMPLETED ON: Group Home / QMRP Case Manager 7-DAY FOLLOW-UP REQUIRED? YES NO

If YES, Who Completes the Follow-Up:

INCIDENT ID#

BDDS Service Coordinator State Form 51677 (4-04) / BQIS 0001