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 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.

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.

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 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.

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 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 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.

Get DC Unusual Incident Report Form 2019-2024

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* Skip this page and attach facility form if applicable. PART IV WHAT ACTIONS WERE TAKEN AND BY WHOM SIGNATURE DATE Completed forms should be faxed to the Licensing and Compliance Unit LCU at 202 -727-7295. 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. 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. 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. 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* Skip this page and attach facility form if applicable. Who What Where and How If necessary attach a separate sheet for additional information* Skip this page and attach facility form if applicable. PART IV WHAT ACTIONS WERE TAKEN AND BY WHOM SIGNATURE DATE Completed forms should be faxed to the Licensing and Compliance Unit LCU at 202 -727-7295. 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.

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