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New York State Department of Health Adult Care Facility INCIDENT REPORT DSS-3123 Rev. 05/12 Facility Name County Date of Incident Time Regulations 487. 7 d 1-13 488. 7 b 1-13 490. 7 d 1-11 Resident Name I. Reportable Incidents to the Department s Regional Office Resident s whereabouts were unknown for more than 24 hours Resident assaults or injures or is assaulted or injured by another resident staff or others Resident attempted or committed suicide if resident died must also check resident death below Complaint or evidence of resident abuse Resident Death A felony crime may have been committed by or against a resident Resident behaved in a manner that directly impaired the well-being care or safety of the resident or any other resident or which substantially interferes with the orderly operation of the facility Resident was involved in an accident on or off the facility grounds which resulted in such resident requiring medical care medical attention or services II. Non-Reportable Incidents are maintained on file in the facility s and/or resident s record III. Incident Description include injuries type of first aid given and employee involvement attach a separate statement of other participants and any witnesses IV. Action Taken describe medical treatments and/or action taken V. Identify individual s or agency s that provided care and location where care was provided Page 1 of 2 VI. Describe current status of the resident s /individual s involved Administrator/Operator s Signature Date VII. Resident s Description of Incident/Accident Operator is required by law to include your description of the incident/accident unless you object or decline. Use the space below for your comments or if you do not wish to comment check the following I do not wish to comment Resident Signature VIII. Reporting of Incident/Accident check all that apply Individual and title of person reporting incident NYS Department of Health Regional Office Date Resident s Physician identify Date Resident s Representative identify Date If Required refer to regulation Police Date State Commission on Quality of Care for the Mentally Disabled if appropriate Date Other identify Date For DOH Internal Use Regional Office Staff Assigned Review Date Central Office Notified YES NO Date. 7 d 1-13 488. 7 b 1-13 490. 7 d 1-11 Resident Name I. Reportable Incidents to the Department s Regional Office Resident s whereabouts were unknown for more than 24 hours Resident assaults or injures or is assaulted or injured by another resident staff or others Resident attempted or committed suicide if resident died must also check resident death below Complaint or evidence of resident abuse Resident Death A felony crime may have been committed by or against a resident Resident behaved in a manner that directly impaired the well-being care or safety of the resident or any other resident or which substantially interferes with the orderly operation of the facility Resident was involved in an accident on or off the facility grounds which resulted in such resident requiring medical care medical attention or services II. Non-Reportable Incidents are maintained on file in the facility s and/or resident s record III. Incident Description include injuries type of first aid given and employee involvement attach a separate statement of other participants and any witnesses IV.