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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How to fill out the DC Unusual Incident Report Form online
The DC Unusual Incident Report Form is crucial for reporting any unusual events that may impact the health, safety, or welfare of enrolled children. This guide will provide you with step-by-step instructions on how to complete the form online effectively.
Follow the steps to complete the form accurately.
- Press the ‘Get Form’ button to access the form and open it in your editor.
- In Part I, Recorded By, fill in your information in the provided fields. Start with your name as the person reporting the incident, the facility name where the incident occurred, your title or position, and the facility’s address. Include your home telephone number and whether you are the director or owner of the facility. Complete the date and time you are reporting the incident, your office number, and your cell number.
- Move to Part II, Incident Information. Start by entering the date and time the incident occurred. Next, specify the date you are reporting the incident. Indicate the type of incident, selecting from accident, injury, or unusual occurrence. If there was suspected abuse or neglect, select yes or no and indicate whether Child Protective Services (CPS) was contacted.
- Continue filling out the incident location address in the provided field. For persons involved, indicate if they are an adult or child and provide necessary details including the child’s age, name, and home telephone number.
- In Part III, describe the incident in detail. Clearly outline who was involved, what happened, where it occurred, and how the situation transpired. If you require more space, you may attach a separate sheet for additional information.
- For Part IV, What Actions Were Taken and By Whom, provide the necessary details. After completing the form, ensure you sign and date it.
- Finally, submit your completed form by faxing it to the Licensing and Compliance Unit at 202-727-7295 or email it to OSSE.ChildcareComplaints@dc.gov for processing.
Complete your incident report online to ensure timely processing and compliance.
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Get answers to your most pressing questions about US Legal Forms API.
What does the incident report form include?
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.
What is an example of an unusual incident?
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.
What is an unusual occurrence incident report?
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.
What are the types of Mui?
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.
Who completes an incident report form?
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.
What is incident with example?
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.
What are some different kinds of 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.
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