Dd-191-Ff - Incident Report - Arizona Department Of Economic Security (Page 2 of 2) in pdf

DD-191-FF (5-14) - PAGE 2

MEMBER’S NAME (Last, First, M.I.)

DATE OF INCIDENT

TYPE OF MEDICAL INTERVENTION (Doctor's visit, urgent care, emergency room, hospitalization)

LOCATION OF MEDICAL INTERVENTION (Site location and address)

NOTIFICATIONS

Serious incidents, as described in the Division's Policy Manual are to be reported and written as soon as possible, but no later than 24

hours after the incident.

All other incidents, as described in the Directive, must be reported to the District office by the close of the next business day following

the incident.

PARENT/GUARDIAN NOTIFIED (If Yes, name of person notified. If No, explain why)

NOTIFIED BY WHOM (Last First, M.I.)

DATE/TIME OF NOTIFICATION

Yes

N/A

SUPPORT COORDINATOR NOTIFIED

Yes

N/A

CHILD/ADULT PROTECTIVE SERVICES NOTIFIED

Yes

N/A

TRIBAL SOCIAL SERVICES NOTIFIED

Yes

N/A

POLICE NOTIFIED

Yes

N/A

PRINT NAME OF PERSON COMPLETING THIS FORM

SIGNATURE OF PERSON COMPLETING FORM

DATE

CORRECTIVE ACTION/COMMENTS

WHAT STEPS ARE BEING TAKEN TO PREVENT THIS FROM HAPPENING AGAIN?

PRINT SUPERVISOR'S NAME

SIGNATURE OF SUPERVISOR

DATE

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans

with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of

the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs,

services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The

Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For

example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair

accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to

take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be

able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance

if at all possible. To request this document in alternative format or for further information about this policy, contact the Division of

Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services

is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente.

Dd-191-Ff - Incident Report - Arizona Department Of Economic Security Page 2

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