Form Dmhas - Follow-Up Incident Report Form October 2015
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2Follow-up Incident Report Form
New Jersey Department of Human Services
Division of Mental Health & Addiction Services
Submit no later than 45 days following the date the incident was known to the agency.
Submit reports to: dmhs.incidentrept@dhs.state.nj.us or Fax # 609-341-2324.
1) UIRMS #: __________________ 2) Incident Date: ________________ 3) County: __________________________________
4) Consumer Name: ____________________________________ 5) Race/Ethnicity: __________________________________
6) Agency Name/Address: _________________________________________________________________________________
7) Reason for this Report:
New Information
Investigation Completed
Other
Status:
Pending
Closed
8) Primary Incident Type: ________________________ Secondary Incident Type (if applicable): ________________________
9) Agency Findings (enter findings for each allegation and/or code):
Primary Incident:
Substantiated
Unsubstantiated
Unfounded
Secondary Incident:
Substantiated
Unsubstantiated
Unfounded
Not applicable
10) Describe the methods used to gather information during agency’s internal review (i.e. consumer/staff interview, review of
policies, procedures and clinical record, etc.):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
11) Describe in detail all NEW/ADDITIONAL information:
(In the event of a death, provide the official cause of death, if known. Attach additional pages as necessary.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
12) Identify all consumer medications:
(Include dosage, route, and frequency for all psychotropic and medical medications.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
13) Does the consumer have a legal status?
No
Yes, specify status: _____________________________________, and
action taken by agency or applicable legal entity: ______________________________________________
14) Summary of analysis/evaluation/investigation:
(In addition, attach, as appropriate, completed Appendices 1, 2, 2a, 3, and/or 4. Attach additional pages as necessary.
Include alleged victim, alleged perpetrator, and witness statements as appropriate.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
15) Agency Finding(s)/Conclusion(s)/Action(s) planned or taken (i.e.: protective, administrative, treatment, disciplinary, and
training actions taken to ensure safety and well-being of consumers):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Advisory, Consultative, Deliberative, Confidential Communication
NJ Department of Human Services 10-2015
Follow-Up Incident Report Form
DMHAS
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