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About
Services
Adult Day Care
Home Modifications
Home Delivered Meals
Medication Management
Non-Medical Transportation
Nursing Home Transition
Skilled Nursing Services
Personal Care
Waiver Process
Enrollment
Providers
Incident Report
1
Demographics
2
Incident Classification
3
Reporter Information
4
Incident Description
5
Initial Action Taken
Individual Demographics:
MCI:
*
Individual Name:
First
Last
Date Of Birth:
*
MM slash DD slash YYYY
Gender:
*
Male
Female
Individual Contact Information:
Phone Number:
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Case Management Details:
SC Entity Name:
*
MCO:
*
SC Name:
*
First
Last
SC Email:
*
Incident Classification
Discovery Date and Time:
*
Primary Category:
*
Abuse
Death
Emergency Room Visit
Exploitation (Participant)
Hospitalization
Neglect
Provider and Staff Misconduct
Reportable Disease
Serious Injury
Service Interruption
Primary Category Date Occurred:
*
MM slash DD slash YYYY
Secondary Category:
*
– Fill Out Other Fields –
Date Occurred:
*
MM slash DD slash YYYY
Add Additional Secondary Category?
*
Yes
No
Secondary Category:
*
– Fill Out Other Fields –
Date Occurred:
*
MM slash DD slash YYYY
Add Additional Secondary Category?
*
Yes
No
Secondary Category:
*
– Fill Out Other Fields –
Date Occurred:
*
MM slash DD slash YYYY
Choking/Falling Indicator:
*
Chocking
Falling
Neither
Was the provider selected the target of an allegation of abuse, neglect, or exploitation?
*
Yes
No
Was this incident referred to Adult Protective Services (18-59 years of age)?
*
Yes
No
Was this incident referred to Adult Protective Services (18-59 years of age)?
*
Yes
No
Date referred to Adult Protective Services/Older Adult Protective Services:
*
MM slash DD slash YYYY
Is the individual's health and welfare at risk?
*
Yes
No
Reporter Information
Reporter Information
*
Participant
Advocate
Friend
Relative
Provider
Relationship to Participant:
*
Friend
General Public
Individual Participant
Non-Reporting Provider Staff
Relative
Reporting Provider Staff
Volunteer
Other
If other, please specify:
*
Name
*
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Incident Description
Description:
*
Location of Incident:
*
Individuals Residence
Individuals Place of Work
Community Site
Other
If community site or other, please explain:
*
Were restraints or restrictive interventions being used during the occurrence?
*
Yes
No
If restraints or restrictive interventions were used, please explain:
Initial Action Taken
Please describe the initial action taken:
*
Type of investigation initiated:
*
Onsite Visit
Telephonic
File Review
Other
Was the participant/victim separated from the target?
*
Yes
No
N/A
If no, please explain:
*
Were supports offered to the participant/victim?
*
Yes
No
N/A
If no, please explain:
*
What supports were offered to the participant/victim?
Medical Attention Given:
Assessment of Injury
CPR Administered
Emergency Room
First Aid
Hospital
Primary Care Practitioner
Urgent Care Center
Other
Not Applicable
If other, please describe:
*
Was a call made to 911?
Yes
No
Unknown
N/A
If no, please explain:
*
Law Enforcement Contacted:
Yes
No
N/A
Other Supports:
Contacted Local Domestic Violence Provider
Contacted Local Rape Crisis Center
Crime Victim Services
Formal Counseling
Housing
Informal Counseling
Mental Health Referral
Natural Supports
Respite
Substance Abuse Counseling and/or Treatment
Other
Not Applicable
If other, please specify:
*
Agencies Contacted
Were any agencies contacted?
*
Yes
No
If yes, please provide details
*
Target Information
Were there targets identified?
*
Yes
No
If yes, plase provide details
*
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E-mail Address
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