Please enable JavaScript in your browser to complete this form.Provider Name & Address *Individual's Name *Date of Birth: *Address *City/County *Date of Incident *Time of Incident *Please also include whether it occured in the AM or PMLocation of Incident (home in bathroom, at the mall, lunchroom at work, etc.) *Description of Incident *Who, what, where, whenInjury – Describe Type and Location *Immediate Action to Ensure Health & Welfare of Individuals: *Name of PPI(s)Relationship to IndividualWitnesses to IncidentOthers Involved:Type of Notification *Guardian/Advocate/FamilySSALicensed or Certified ProviderStaff or Family living at the Individual’s homeLE (Name, Badge Number, Jurisdiction, Contact InfoChildren’s Services (if applicable)County BoardAdministrator (Required for ICF)Senior ManagementOther Providers of ServiceType of Notification – Names, Titles, Days, and Times *Please list out the names and titles of individuals notified that you checked above, including day and time they were notified.Additional Information or Administrative Follow-Up – Part A *Further Medical Follow-Up:Additional Information or Administrative Follow-Up – Part B *Administrative Action if "None" Address Name/Signature *Title *Date *Body Part Injured – Select "None" if not applicable *Head or FaceMouth/TeethHands/ArmsFeet/LegsNeck or ChestAbdomenBack/ButtocksGenitalsNoneDetailed description of area(s) injured: *Type “None” if not applicableCheck All Areas Injured – ANTERIOR (Front of body) – Select "None" if not applicable *HeadNeck/CollarboneRight ShoulderLeft ShoulderChestRight ForearmLeft ForearmRight HandRight ThighGenitalsLeft ThighLeft HandRight Knee/ShinLeft Knee/ShinRight FootLeft FootNoneSelect “None” if not applicableCheck All Areas Injured – POSTERIOR (Back of body) – Select "None" if not applicable *HeadNeck/CollarboneRight ShoulderLeft ShoulderBackRight ForearmLeft ForearmRight HandRight ThighGenitalsLeft ThighLeft HandRight Knee/ShinLeft Knee/ShinRight FootLeft FootNoneCauses and Contributing Factors *Preventative Measures (For Provider's Internal Use) *Administrator ReviewReview Date *Submit
