Get Az Ddd-0191a 2018

The AZ DDD-0191A form is a crucial document used to report incidents involving members of the Arizona Division of Developmental Disabilities. This guide provides step-by-step instructions to complete the form online accurately and efficiently, ensuring that all necessary information is gathered.

Follow the steps to complete the AZ DDD-0191A online.

1. Press the ‘Get Form’ button to access the AZ DDD-0191A form electronically.
2. Begin by entering the member’s name in the format of Last, First, Middle Initial. Make sure this is accurate as it is essential for identification purposes.
3. Input the Focus ID, which is a unique identifier for the member. This ensures that the incident report is linked to the correct individual.
4. Fill in the birth date using the format Month, Day, Year. This information is necessary for verifying the member's age.
5. Indicate whether the member is in foster care by selecting 'Yes' or 'No'. This helps to provide context for the report.
6. Enter the name of the Vendor or Independent Provider responsible for the member at the time the incident occurred.
7. Complete the Reporting Vendor or Independent Provider Name/Address section, if it differs from the previous details, including the city, state, and ZIP code.
8. Specify the service being provided at the time of the incident to contextualize the situation.
9. Record the location of the incident (e.g., Group Home, Day Treatment, Family Home) along with the site name and address.
10. Document the date and time of the incident, ensuring they are accurate to the best of your knowledge.
11. List the staff involved in the incident, starting with the first staff member's name and phone number, followed by their immediate supervisor's name.
12. Continue to document additional staff involved, their contact information, and supervisors.
13. In the section labeled 'Describe Incident Thoroughly', provide a detailed account of what happened before, during, and after the incident. Write objectively and sequentially.
14. Indicate the type of medical intervention required, if any, and provide the name and address of the facility where treatment was administered.
15. Fill out the notifications section by indicating whether the parent or guardian, support coordinator, and protective services were notified, along with respective details and justifications.
16. In the 'Corrective Action/Comments' section, suggest measures that will be taken to prevent similar incidents in the future.
17. Finally, enter the name and signature of the person completing the form, along with the supervisor's name and signature.
18. Once all information is complete, save the changes and choose to download, print, or share the completed form as needed.

Complete your document online today!