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  • Dc Unusual Incident Report Form 2019

Get Dc Unusual Incident Report Form 2019-2025

UNUSUAL INCIDENT REPORT FORM Title 5A DCMR Chapter 1 128. 1 - A Licensee shall immediately notify OSSE of any unusual incident that may adversely affect the health safety or welfare of any enrolled child or children by submitting a completed OSSE Unusual Incident Report form to OSSE s Child Care Complaint email address. PART I REPORTED BY 1. PERSON REPORTING INCIDENT FACILITY NAME TITLE/POSITION ADDRESS Home Telephone Number with area code DIRECTOR/OWNER DATE REPORTED OFFFICE NUMBER CELL NUMBER PART II INCIDENT INFORMATION 2. Date of Incident 3. Time of Incident 4. Date of Report 5. Type of Incident Accident Injury Unusual Occurrence 6. Suspected Abuse or Neglect Yes No Was Child Protective Services CPS contacted Yes No move to the next section 7. Incident Location Address 8. Person Involved Adult Child Child s Age Name Last First Middle Rev* 03-2019 PART III DESCRIPTION AND DETAILS OF INCIDENT 10. Who What Where and How If necessary attach a separate sheet for additional information* ....

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Include details about what happened before the incident, the incident itself, and actions that were taken immediately after. If you are writing down your opinion of what caused the incident or what you think happened, be sure to note that it is an assumption.

I. UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or emotional health or safety of any resident and epidemic outbreaks, poisonings, catastrophes, facility fires or explosions.

An MUI will fall into one of the following categories: substantiated, unsubstantiated/ insufficient evidence, or unsubstantiated/ unfounded. “Substantiated” means there is a preponderance of evidence that the alleged incident occurred.

The person who has been injured, any witnesses to the incident and the direct supervisor should all complete the form. If the person involved in the incident is unable to complete the form for any reason, it should be completed by the person's direct supervisor.

Incident can refer to any event – big or small, good or bad, intentional or unintentional. A bank robbery, a funny or controversial situation, an argument between celebrities, etc. – all can be described as incidents.

While many types of incidents can happen, here are the most common types of incidents that occur in the workplace today: Positive Observations. ... Unsafe Acts. ... Near Misses. ... Minor Injuries. ... Lost Time Accidents. ... Fatalities.

The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232