Report an Unusual Incident or Major Unusual Incident

Provider Name*

Contact Person (if agency)*

Contact Person's Phone*

Provider's Address*

Provider's Email*

Individual's Name*

Individual's Date of Birth*

Individual's Address*

Date of Incident*

Time of Incident*

Location/Address of Incident*

Description of Incident*

Injury Description*

Immediate Action Taken*

Contributing Factors*

Primary Person Involved (PPI)*

Relationship of PPI to Individual*

Witness to Incident

Statement of Witness

Names of Others Involved

Follow-up/Prevention Statement

Notifications

I have notified the following people about this incident:

Guardian/Advocate SSA/QIDP Licensed or Certified Provider Staff or Family Member Responsible for Care Law Enforcement/Child Protective Services Clark DD IA Department Any other person notified

Supervisor Action

Complete with information about any action taken by your supervisor.

Administrative Action

Signatures

Signature (typing your name here indicates you are signing this document) *

Signature of Supervisor (typing your name here indicates you are signing this document)