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Get OH DODD Incident Report Form

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 Body Part Injured 0 Head or Face 0 Mouth / Teeth 0 Hands / Arms 0 Feet / Legs 0 Other Title Date Neck or Chest Abdomen Back / Buttocks Genitals Causes and Contributing Factors Preventive measures For Provider s internal use Date. 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 Body Part Injured 0 Head or Face 0 Mouth / Teeth 0 Hands / Arms 0 Feet / Legs 0 Other Title Date Neck or Chest Abdomen Back / Buttocks Genitals Causes and Contributing Factors Preventive measures For Provider s internal use Date. .

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