Unusual Incident Monthly Report Log For Independent Providers Form

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Unusual Incident Monthly Report Log for Independent Providers

All information needed to complete this form should come from the corresponding Unusual Incident Report that has already been completed.

Independent

Provider

Provider Name:

Address:

Email Address:

Month:

Year:

Providing services for the following consumers:

Name

Date

Injury

Location

Description of Incident

Immediate Action Taken to

Causes &

Prevention Plan

and Time

(Explain Risk of Harm)

Ensure Health & Welfare

Contributing Factors

Reviewed By:

Title: Independent Provider

Date:

Trends and Patterns Identified?

YES

Trends and Patterns Addressed?

YES

(If YES, please complete section below.)

Action taken to address identified Patterns and Trends:

O.A.C. 5123:2-17-02(M)(6) Each independent provider shall review all unusual incidents as necessary, but no less than monthly to ensure appropriate preventative measures have been

implemented and trends and patterns identified and addressed as appropriate. O.A.C. 5123:2-17(M)(8) Each 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 preventative measures.

This form is to be completed, reviewed, and stored by the Independent Provider.

12/2013, revised 01/24/2014

Submitted by, Printed Name:

Date:

By checking this box, I agree that my printed name I have entered above, will be the legal electronic representation of my signature.

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