Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of UBS *Name of Person Completing Form *Title: *Contact Information *Date Form Completed *MUI Number *Provider: *UBS/History AntecedentsPlease list what led to UBS. Provide a time line and whether this individual has a history of this behavior. Provider details of prevention measures from prior incidents. How many times was the intervention/support used? How long (total) was the individual restrained?Behavior StrategiesDid the individual have behavioral support strategies outlined in their service plan? Did the staff know about the strategies? Was the staff trained on the implementation of the behavioral support strategies?Type of UBS – Physical Restraint (Check all that apply)BasketholdMultiple Person CarryMultiple Person EscortOne Person CarryOne Person EscortOne Person RestraintPhysically Prompted Hands Down with ResistanceProneRestraint of Multiple AppendagesSeated RestraintSide RestraintStanding RestraintSupineTime Out (List details of time-out, including length of time, below)Other (explain below)Type of UBS – Chemical Restraint (Check all that apply)Anti-AnxietyAnticonvulsantAntidepressantAntipsychoticMood StabilizerOther (explain below) Factors Explanation Completed Type of UBS – Mechanical (Check all that apply)Full Body-papoose Board WrapFull Body-seated PositionFull Body-supine PositionGait BeltHelmetLocked Seat Belt/Vest – not during transportationMittsSplintsTransportation – locked seatbelt/vest/othersWheelchair controls disabledWheelchair for individual – not used regularlyOther (explain below)Type of UBS ExplanationList details of time-out, including length of time. Explain your “other” checkbox here.InjuriesWere there any injuries to the individual or anyone else involved in the UBS? Did the individual receive timely medical attention?DescriptionDescribe in detail the intervention/support and the reason used. How was it necessary for the health and welfare if individual or other individuals?Cause & Contributing Factors (Check all that apply)Supervision Not MetStaff Ratio Not AppropriateDiet Not FollowedAsked to Complete TaskChange in RoutineExcessive Noise1:1 Attention UnavailablePeer AggressionOuting CancelledControl Issues – Staff/Family/PeersMedication ChangesIllnessPossible HallucinationLoss of Important RelationshipISP/BSP Not FollowedCause & Contributing Factors – OtherPrevention Measures (Check All That Apply)Physical/Social environmental changesAgency Policy/System ChangeStaff trainingCounselingTeam meeting to address ISP changesAppointment with Medical care providerMedication changesFollow up appointment scheduledPT/OT/Speech referral made to addressCommunication or mobility concernDiet change orderedHome health carePrevention Measures – OtherInvestigative Agent Review – Comments & Questions *IA Name: *Review Completed Date: *Submit
