Misconduct Incident Report printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Quality Assurance

DHS 13.05(3)(a), Wis. Admin. Code

F-62447 (Rev. 04/10)

Page 1 of 8

MISCONDUCT INCIDENT REPORT

GENERAL INSTRUCTIONS

Use this form to report incidents of alleged misconduct (client abuse or neglect or misappropriation of client property) and injuries of unknown

source. The Department reviews this report to determine whether further investigation of the incident is warranted. So that the Department may

make this determination, please complete the Misconduct Incident Report in its entirety. Use the following information as guidance when

completing this form.

I. ENTITY INFORMATION (Page 3)

The entity or facility named is the entity responsible for the care of the affected person. The Department will send all responses regarding the

report to the entity reporter and address listed in this section.

ENTITY TYPE CODES

Code

Entity Type

Code

Entity Type

Emergency Mental Health Service Programs

105

Personal Care Agency

Mental Health Day Treatment Services for Children

124

Hospitals

Outpatient Community Mental Health/Dev. Disabilities

127

Rural Medical Centers

Community Support Programs

131

Hospices

Community Substance Abuse Services (CSAS)

132

Nursing Homes

Certified Adult Family Homes

133

Home Health Agencies

Community Based Residential Facilities

134

Facilities for Persons with Developmental Disabilities

Licensed Adult Family Homes

000

Other (Specify.)

Resident Care Apartment Complexes

II. SUMMARY OF INCIDENT (Pages 3 and 4)

Indicate when the incident occurred. Include the month, day, year, and time of the incident (e.g., 08/25/2003, 10:30 AM). If you do not

know the exact day, provide an approximate date (e.g., the week of March 1, the month of March, between March 1 and April 15). If you

give approximate dates, explain how you determined the dates.

Briefly describe the incident. Summarize the incident in the space provided, even if more details or documents are attached.

Describe the effect of the incident upon the affected person or the person’s reaction to the incident. If a person has been

physically injured, describe the injury, the size of the bruise, etc. A photograph of the injury is very helpful. If photographs are taken,

identify when the photos were taken, how many were taken and by whom. Describe any indication or expressions of pain, anger,

frustration, humiliation, fear, etc. by the person during or after the incident.

Explain what the entity did, upon learning of the incident, to protect the person(s) from further potential misconduct. Describe

the steps that the entity took to protect the person(s) from subsequent potential episodes of misconduct while a determination on the

matter is pending. Indicate the accused person’s current employment status and date of any employment action after the alleged incident.

NOTE: The entity is not required to terminate the employment of an accused person to meet protection requirements.

Check the specific location where the incident happened. If the incident happened at a location other than the entity, indicate the

specific address of that location.

III. AFFECTED PERSON INFORMATION (Page 4)

Include the affected person’s name, date of birth, gender, address, and telephone number. If the affected person has been adjudicated

incompetent, is under age 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of

the parent, guardian, or legal representative.

IV. ACCUSED PERSON INFORMATION (Page 4)

Include the accused person’s name (if known), social security number, position or title at the time of the incident, date of birth, gender, current

home address, and home telephone number. Entities must inform the accused person that a report regarding the incident is being filed with

the appropriate authority. If the accused person is currently employed by an entity other than the reporting entity, include the name, address,

and telephone number of the current employer. If the accused person is under age 18, provide the name, address, and telephone number of a

parent or guardian. If there is more than one accused person, complete this section for each person.

V. LAW ENFORCEMENT INVOLVEMENT (Page 5)

Check if law enforcement was contacted or is involved. Indicate the officer’s name, department, address, telephone number, and---if available-

--the case number. Attach a copy of the law enforcement incident report, if available.

VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT (Page 5)

Include all persons with specific knowledge of the incident. Include the person’s name, gender, address, and telephone number. Check

whether the person is an entity employee. Include the person’s position at the entity or relationship to the affected person. Attach additional

pages, as necessary.

Misconduct Incident Report

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