Get Ca Reportable Incident Reporting Form - Los Angeles County 2017-2025

Filling out the CA Reportable Incident Reporting Form for Los Angeles County is an essential step in reporting significant incidents within healthcare settings. This guide offers clear instructions on how to complete the form online efficiently and accurately, ensuring that all necessary details are provided.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in an editor.
2. Enter the patient's name in the format of last name, first name, and middle name in the designated field.
3. Input the patient's date of birth using the format mm/dd/yyyy.
4. Enter the patient's Medi-Cal or My Health LA (MHLA) number; if unknown, leave the field blank.
5. Fill in the patient's address in the provided space.
6. Record the patient's phone number and indicate whether it is okay to leave a message.
7. Select the patient's gender from the options provided.
8. Specify the patient's preferred language in the appropriate field.
9. Indicate the patient's race/ethnicity as requested on the form.
10. Provide the name of the provider agency where the incident occurred.
11. Enter the name of the contact person at the provider agency.
12. Input the contact person's phone number.
13. Fill in the provider agency's address.
14. Enter the email address of the provider agency or contact person.
15. Specify the date of the incident in the format mm/dd/yyyy.
16. Document the time of the incident.
17. Describe the nature of the incident, including details such as date, people involved, and witnesses.
18. List any pre-disposing factors or root causes relevant to the incident.
19. Detail the staff response to the incident, including any interventions applied.
20. Outline any case reviews, trainings, or changes to policies initiated in response to the incident.
21. Enter the name of the reporting staff member and the date of the report.
22. Once completed, save your changes, then download, print, or share the form as necessary.

Complete the CA Reportable Incident Reporting Form online today to ensure proper documentation of incidents.