Dd-191-Ff - Incident Report - Arizona Department Of Economic Security printable pdf download

Dd-191-Ff - Incident Report - Arizona Department Of Economic Security

DD-191-FF (5-14)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

INCIDENT REPORT

Confidential Information

Please Print

• Division staff may use this form to ensure all pertinent incident information is gathered.

• Providers may use this form or write all pertinent incident information on a separate report to the Division.

MEMBER’S NAME (Last, First, M.I.)

FOCUS ID NO.

BIRTHDATE

MEMBER’S ADDRESS (No., Street, City, State, ZIP)

FOSTER CARE

Yes

PROVIDER NAME AT TIME OF INCIDENT (Qualified Vendor, Individual Independent Provider, Provider Site Name)

NAME AND LOCATION OF INCIDENT (Site Name, No., Street, City State, ZIP)

DATE OF INCIDENT

TIME OF INCIDENT

STAFF/WITNESS(ES) INVOLVED IN INCIDENT (Last, First, M.I.)

PHONE NUMBER

IMMEDIATE SUPERVISOR

(

)

N/A

PHONE NUMBER

IMMEDIATE SUPERVISOR

(

)

N/A

DESCRIBE INCIDENT THOROUGHLY. (What happened before, during and after the incident. Include all known facts, causes of injury and

emergency measures, if applicable. Write clearly, objectively and in order of occurrence, without reference to the writer's opinion.)

WHAT HAPPENED BEFORE THE INCIDENT?

WHAT HAPPENED DURING THE INCIDENT?

WHAT COULD HAVE PREVENTED THE INCIDENT?

Form is continued on reverse (page 2)

See reverse for EOE/ADA/LEP/GINA disclosures

Dd-191-Ff - Incident Report - Arizona Department Of Economic Security