Fillable Dd-191-Pf - Incident Report (Page 2 of 2) in pdf

Dd-191-Pf - Incident Report Page 2

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DD-191-PF (12-05) - PAGE 2

INDIVIDUAL'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 and Procedures Manual Administrative Directive 76, 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 Disability Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the

Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex,

national origin, age, and disability. 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 of 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) 542-6825; TTY/TTD

Services: 7-1-1.

Dd-191-Pf - Incident Report Page 2

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