UI Monthly Report Log for Independent Providers

Unusual Incident Monthly Report Log for Independent Providers

UI Description

This form is to be completed, reviewed, and stored by the Independent Provider every month.

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All information needed to complete this form should come from the corresponding Unusual Incident Report that has already been completed.

Independent Provider Name *

Provider Address *

Email *

Month *

Year *

Providing services for the following consumers *

Name *

First

Last

Date / Time *

Date

Time

Injury *

Description of Incident (Explain Risk of Harm) *

Immediate Action Taken to Ensure Health & Welfare *

Causes & Contributing Factors *

Prevention Plan *

Reviewed By *

Date *

Trends and Patterns Identified? *

Trends and Patterns Addressed? *

(If YES, please complete section below.)

Action taken to address identified Patterns and Trends

Submitted by *

Date *

Signature *

By checking this box, I agree that my printed name I have entered above, will be the legal electronic representation of my signature. *

I agree

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