Acbdd Ui Report Template
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1Pg. 2 ACBDD UI Report
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Witnesses:
OTHER(S) INVOLVED:
**************NOTIFICATIONS
: (Notify
SAME DAY of incident and/or discovery)*************
SUPERVISOR
Date: __________
Time: ___:____ AM / PM
PARENT
Date: __________
Time: ___:____ AM / PM
SSA / Case Mgr.
Date: __________
Time: ___:____ AM / PM
Specialist / Teacher Date: __________
Time: ___:____ AM / PM
Investigative Agent Date: __________
Time: ___:____ AM / PM
Nurse
Date: __________
Time: ___:____ AM / PM
Children Services
Date: __________
Time: ___:____ AM / PM
Transportation
Date: __________
Time: ___:____ AM / PM
Law Enforcement
Date: __________
Time: ___:____ AM / PM
PROVIDER
Date: __________
Time: ___:____ AM / PM
Other _____________Date: __________
Time: ___:____ AM / PM
GUARDIAN
Date: __________
Time: ___:____ AM / PM
NURSE COMPLETES THIS SECTION
:
Location on the body where injury occurred:
Briefly describe Injury & treatment:
Photos taken?: No Yes (# taken:_____) ♦ Emergency Transport needed? No Yes HOSPITAL:
♦ Staff person going to hospital:
♦ EMA sent w/ staff or individual? Yes No
NURSES SIGNATURE:
Date:
NOTIFICATION: Called Family / Provider
Note sent home
Follow-up recommended
(Date)
(Date)
:
UI / MUI
Provider at time of Incident: A/C - H/H – Transp – Waiver – ICF - Family (circle)
ADMINISTRATOR section
(circle)
Individual:
IDS#: _________________________ Incident written by: ___________________________________
UI Date: _______________ Time: __________ Discovery Date: ________________ Time: __________ LOCATION:
Injury: Yes No N/A BSP addresses Behavior : Yes No N/A
TYPE of Incident: __________________________________
Injury: Yes No N/A BSP addresses Behavior : Yes No N/A
Name of PPI? ________________________________________
Incident SUMMARY: __________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
CAUSE: _________________________________________________________________________________________________________
IMMEDIATE ACTION by STAFF:______________________ ______________________________________________________________________
______________________________________________________________________________________________________________________________________
What will be done to decrease incidents or prevent incidents from occurring again
: ________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Adm. Signature: _________________________________________________________________ Date: ________________________________________________
OFFICE USE:
cc: Superintendent _______ Dir. of Ed._______ CSS Dir._______ A/C Dir._______ Prod. Mgr._______ SSA _______ ISS Dept. _______
(Date)
(Date)
(Date)
(Date)
(Date)
(Date)
(Date)
Provider_______ Parent_______ Guardian_______ Other
(Date)
(Date)
(Date)
(Date)
Revised 4/19/11
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