Incident Report Medicaid Waiver Programs
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
Completion of this form meets the
F-22541 (03/2017)
requirements and conditions of the
CMS-approved Medicaid Waiver programs
INCIDENT REPORT – MEDICAID WAIVER PROGRAMS
Instructions: This form may be completed in stages but must eventually be completed in its entirety. It is
applicable to all children and adults receiving services through the CLTS and IRIS Medicaid Waiver programs.
Additional information may be attached to supplement but not replace information provided on the report form. This form
must be submitted via email, mail or fax to the designated Contact for the specific Waiver program. Failure to report
incidents as required or in a timely manner may result in a full or partial disallowance of the funding claimed for the subject
of the incident if it is determined that the participant’s safety was not assured by the waiver agency.
TIMELINES: If a Critical Incident, report to waiver agency WITHIN 24 HOURS. Agencies: Notify state contact staff
within THREE BUSINESS DAYS of the initial report. For additional requirements, see the instructions (F-22541i)
PARTICIPANT INFORMATION
1. Name - Last
Name - First
MI
2. Address – Street (Participant)
City / State / Zip Code
3. Date of Birth
4. Sex
5. Telephone Number
(
)
Male
Female
6. Name – Residential Service Provider
Address – Residential Service Provider
7. County of Physical Residence
8. County of Fiscal Responsibility
9. Waiver Program
10. MCI Number
CLTS
DD
PD
SED
IRIS
INCIDENT INFORMATION
11. Date of Event
12. Location Event Occurred (Street, City, State, Zip Code)
13. Name – Reporting Provider (Individual / Agency)
Reporting Provider Contact Information (Telephone No., Email)
14. Type of Report (Check all that apply)
Critical
Original
Update
Correction
Incident Review Completed and Closed
15. Type of Setting Where Incident Likely Occurred
Residence
Natural or adoptive home (with parents)
Adult family home, 1-2 bed
Person’s own home
Adult family home, 3-4 bed
Children's foster home / treatment foster home
CBRF
Other
School
Respite provider site
Child care center
Another person's residence
Work site in community
Waiver transportation provider, public
Work site—congregate vocational provider
Waiver transportation provider, agency or individual
Day activity site
Public transportation provider- not waiver funded
Day treatment program
Other – Specify:
Community Setting—park, store, etc.
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