Get Unusual Incident Report

This guide provides a clear and detailed overview on how to successfully complete the Unusual Incident Report online. By following these steps, users can ensure that all necessary information is accurately captured and submitted.

Follow the steps to complete the Unusual Incident Report online:

1. Click the ‘Get Form’ button to access the report and open it in your preferred online editing tool.
2. Select whether to enter the License number or Certification Residential Facility number by checking the appropriate box. Only include one number.
3. Fill in the date of the report and the date of discovery in the designated fields.
4. Input the provider-generated incident number, if available, along with the provider name.
5. Provide the provider's telephone number, making sure to include the area code.
6. Indicate the name of the ADAMH/CMH Board to which the incident was reported.
7. Enter the provider's email address and the full provider address, including street, city, state, and zip code.
8. Identify the name and title of the contact person regarding the incident and their telephone number if different from the agency number.
9. Record the time and date of the incident, marking unknown where applicable.
10. Select the incident type from the provided options, ensuring accuracy.
11. List all notifications made regarding the incident by checking all applicable boxes.
12. Provide HIPAA-compliant identifiers for client/resident information, including age, gender, and race/ethnicity.
13. If applicable, select the medications involved and indicate whether a minor was involved in any sexual assault.
14. Identify others involved in the incident by checking all applicable boxes.
15. If another client/resident was involved, indicate whether an incident notification was filed.
16. Complete the additional information section without using names and report any staff injuries related to the incident.
17. If restraint and/or seclusion was employed, provide details including total minutes of each type.
18. Sign the form and enter the date of completion.
19. Once all sections are completed, users can save their changes, download, print, or share the form as needed.

Complete the Unusual Incident Report online to ensure timely and accurate reporting.