Free 46009.FH11 - Indiana

REPORT OF INCIDENT / INJURY
State Form 46009 (R2 / 8-07)

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The information in this document is confidential according to 45 CFR 160 and 164, IC 16-39, and 42 CFR Part 2. Date of incident (month, day, year) Time (24 hour) Location of incident (ward / area)

INCIDENT INFORMATION (for incident reported)
Date of report (month, day, year) Time (24 hour)

DETAILED INCIDENT LOCATION (check one)
AR BA BE CL AP AV AW BM CH CI CO CS Activity / Rec. Bath Room Bed Room Classroom CA DR HA KI Clinic Area Dining Room Hall Kitchen CU DP EB EC EF ER FA FI LR LO NS PL Living Room Lobby Nurse Sta. / Off. Parking Lot FM FR FU IG IN IS LI ME RA RO SH SE Ramp Roadway Shop Seclus / Time Out SW SM ST VE MI OH PD SA SE SI SS ST Sidewalk Smoking Stairs Vehicle WV OR OF UN Work / Vocational Other Off Grounds Unknown Theft ** Trespass Vehicle Accident Other

INCIDENT TYPE (** alleged)
Alcohol Poss / Con Attack / Verbal ** AWOL / Elopement Behavior Mgmt Choking Contact / Intentional ** Contraband Contact / Sexual ** Contact / Unintentional ** Drug Possess. / Con Exposure/Blood/Body Fluids Expos / Dangerous Chem Environmental Factors Equipment Related Fall Fire / Intentional Failure / Medical Equip Failure / Follow MD/RN Order Fire / Unintentional Ingestion / Foreign Object Injury / Unknown Origin Illness / Sudden Onset Lifting Medication Error Medicine Incid / ADR Overheating / Heat Prost Property Destruction Suicide Attempt / Gesture Seizure Self-Injurious Behavior Severe Sunburn Suicide Threat Person's Role PP Perpetrator VI Victim WI Witness MI TH TR VA OR

INFORMATION REGARDING INDIVIDUALS INVOLVED IN INCIDENT (use letters from categories below) Person's Category Role I.D. Number Name Age Diag.
Person Category CE Contract Employee EE Employee DO DOC Offender PA Patient / Client VI Visitor VO Volunteer Diagnosis Mentally Ill DD Developmentally Disabled DA Drug / Alcohol OR Other

INJURY (check applicable categories)
Type of Injury AB BI BF BU CO EP LA MI NS PS PU SC ST SB SW OR NO Abrasion Bite Break / Fracture Burn Contusion / Bruise Bloody Nose Laceration / Cut Muscle Injury Needle Stick Poss Break / Fracture Puncture Scratch Sting Sunburn Swelling Other No Injury MT RE LE RR LR NO HF NE CH AD BK GE BU RA LA FI RL LL TO OR Body Part Affected Mouth / Teeth Right Eye Left Eye Right Ear Left Ear Nose Head / Face Neck Chest Abdomen Back Genitalia Buttocks Right Arm / Hand Left Arm / Hand Fingers Right Leg / Foot Left Leg / Foot Toes Other AM CK CN EV EQ FU IN LI MD NS OT SE SI SU SP WI OR UN Apparent Cause Animal Chemical / External Chemical / Internal Environmental Factors Equipment Furnishings Insect Lifting Medical Devices Non-staff person Other Patient / Client Seizure Self - intentional Self - unintentional Staff Person Water Intoxication Other Unknown / Unknown Origin NT FA DX MF RE Treatment Given No Treatment First Aid Diag / Exam / Tests More Than First Aid Referral Treatment Location IN ON OF Incident Location On Grounds Med. Facility Off Grounds Med. Facility

ADDRESSOGRAPH

Treatment Given By OR FS FP NF Other Facility Staff Facility Nurse Facility Physician Non-facility Staff

DESCRIPTION OF INCIDENT
Brief, essential information, no opinions/conclusions, no clients names

Signature

Title

Date (month, day, year)

Continued on reverse side

NURSING COMMENTS
Brief, essential information, no opinions/conclusions, no client names

Signature

Date signed (month, day, year)

PHYSICIAN COMMENTS
Brief, essential information, no opinions/conclusions, no client names

Signature

Date signed (month, day, year)

INTERNAL NOTIFICATIONS (if applicable)
Supervisor notified / reviewed Date notified (month, day, year) Time notified Nurse notified / reviewed Date notified (month, day, year) Time notified Physician notified / reviewed Date notified (month, day, year) Time notified Security notified Comment

Yes AGENCIES NOTIFIED OF THE INCIDENT (see listing below) Agency Type Name of Agency (use only if not listed) Date (month, day, year) Time Name of Person Notified

No

Name of Person Who Notified

AGENCY LIST
AP CA DF Adult Protect Service Child Welfare Div. of Family Resources DH DM DA Dept of Health Div. of Mental Health & Addiction Div. of Aging & Rehabilitation NK GM HC Next of Kin Guardian Health Care Rep SP SS OR State Police Secret Service Other