Unusual Incident Report Log
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1UNUSUAL INCIDENT REPORT LOG
Month/Year:
Provider/Facility:
County:
Name
UI #
Date & Time
Injury
Home Name and
Location
Description of the Incident
Immediate Actions Taken to Ensure
Causes and Contributing
Prevention Plan
UI/MUI
Factors
Address
(Explain the risk of Harm)
Health and Welfare
Reviewed by:_______________________________________________________ Title:_______________________ Date:____________________
Trends and Pattern Identified?
YES NO
Trends and Pattern Addressed?
YES NO If yes, please complete section below.
Action taken to address identified Patterns and Trends:
O.A.C. 5123:2‐17‐02 (M)(8) Each agency provider and independent provider shall maintain a log of all unusual incidents. The log shall include, but is not limited to, the name of the individual, a brief description of the unusual incident, any
injuries, time, date, location, and preventive measures.
DODD MUI 7/22/13
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Parent category: Miscellaneous