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  • Oh Dodd Incident Report Form

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Provider Name Address DODD Possible or Determined MUI Report Form Individual s Name DOB Address City/County Date of Incident Time of Incident AM/PM Location of Incident home in bathroom at the mall lunchroom at work Description of Incident Who W hat Where When Injury Describe Type Location Immediate Action to Ensure Health Welfare of Individuals Name of PPI s Relationship to Individual Witnesses to Incident Others Involved Type of Notification Guardian / Advocate SSA required for Independent Providers0 Licensed or Certified Provider Staff or Family living at the Individual s home responsible for the individual s care. LE Name Badge Number Jurisdiction and contact information required for Law Enforcement Enforcement CPSA Name and contact information required for Children Services County Board Administrator Required for ICF Support Broker If applicable Name/Title Date/Time Additional Information/or Administrative Follow-Up A. Further Medical Follow-up B. Administrative Action Signature....

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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.

Notification to the County Board about the below listed incidents within 4 hours of discovery: Accidental or suspicious death; Exploitation; Misappropriation; Neglect; Peer-to-peer act; Physical abuse; Prohibited sexual relations; Sexual abuse; Page 2 Verbal abuse; and When the provider has received an inquiry from the ...

Unfounded means available information indicates that, more likely than not, child abuse or neglect did not occur. No unfounded allegation of child abuse or neglect may be disclosed to a child-placing agency, private adoption agency, or any other provider licensed under chapter 74.15 RCW.

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.

Major unusual incidents, also called MUIs, are alleged, suspected, or actual occurrences of an incident when there is reason to believe the health and welfare of a person may be adversely affected or the person is placed at a likely risk of harm. MUIs are reported so they can be investigated.

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.

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© Copyright 1997-2025
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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