Get Az Ddd-0191a 2023-2026

The AZ DDD-0191A form is a vital tool for reporting incidents within the Arizona Division of Developmental Disabilities. This guide provides clear, step-by-step instructions for completing the form electronically, ensuring that all required details are accurately recorded.

Follow the steps to fill out the AZ DDD-0191A online.

1. Press the ‘Get Form’ button to access the AZ DDD-0191A form and open it in the editor.
2. Begin filling out the confidential information section, including the member's assigned district and the district where the incident occurred. Be sure to select the correct options from the provided choices.
3. Enter the date and time of the incident, along with the member's name, date of birth, and AHCCCS ID. Ensure all personal information is accurate.
4. Indicate whether the member is in foster care and whether a behavior plan is required. If a behavior plan is necessary, check if it is current.
5. Complete the details regarding the Person-Centered Service Plan (PCSP), including its date and whether it identifies the need for an enhanced supervision ratio.
6. Fill in the vendor or independent provider’s name responsible for the member at the time of the incident, along with their contact information and site address.
7. Provide detailed descriptions of the service provided at the time of the incident and the names of individuals or staff involved in the incident.
8. If related to medication, answer the additional questions regarding medication administration, including details about any errors that occurred.
9. For incidents unrelated to medication, complete the incident type section with as much detail as possible regarding what occurred before, during, and after the incident.
10. Document notifications made to the parent, guardian, support coordinator, protective services, and law enforcement, if applicable.
11. Use the corrective action/comments section to summarize measures taken to prevent future incidents and complete the form with your electronic signature and date.
12. Once you have completed the form, save the changes, download a copy, print it, or share it as required.

Complete your documents online to ensure accurate reporting and prompt incident management.