Unusual Incident Report

Individual’s Name *

First

Last

Individual's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Provider Contact Person *

First

Last

Phone Number *

Date and Time Incident Occurred *

Date

Time

Date and Time Incident Discovered *

Date

Time

Specific Location Where Incident Occurred *

Date and Time Incident Reported *

Date

Time

Supervisor *

Date and Time Reported to IA

Date

Time

for MUI only

Description of Incident *

(who, what, when, where)

Witnesses

Name

First

Last

Title

Phone

Name

First

Last

Title

Phone

Name and Relationship of Primary Person(s) Involved and their relationship to individual *

(Primary Person Involved means the person alleged to have committed or to have been responsible for abuse, accidental or suspicious death, exploitation, failure to report, misappropriation, neglect, prohibited sexual relations, or rights code violation.)

Did Injury Occur *

Assessment Completed by Whom? *

First

Last

Title *

Date *

Describe immediate action taken to ensure health and welfare of the individuals involved and any at-risk individuals *

Describe any further medical follow-up required *

REQUIREMENTS FOR IMMEDIATE REPORTING TO INVESTIGATE AGENTS (IAs)

Alleged Abuse, Neglect, Exploitation, Misappropriation, Peer-to-Peer Acts, Prohibited Sexual Relations, Accidental or Suspicious Death, or Media Inquiries about an MUI must be verbally reported to an IA within 4 hours of the discovery of the incident.

REQUIRED NOTIFICATIONS FOR A UI

UI notification to other providers of services as necessary to ensure continuity of care and support for the individual.

Provider Name *

Title *

Date / Time *

Date

Time

Provider Name

Title

Date / Time

Date

Time

Provider Name

Title

Date / Time

Date

Time

Independent providers must notify guardian/identified other and send completed UI Report to SSA by the next working day after discovery of UI.

Guardian/Identified Other *

Date / Time *

Date

Time

SSA *

Date / Time *

Date

Time

REQUIRED NOTIFICATIONS FOR A POTENTIAL OR IDENTIFIED MUI

The following MUI notification must be made on the day of occurrence, or discovery, of an MUI incident and include immediate action taken.

Guardian/Identified Other

Date / Time

Date

Time

SSA

Date / Time

Date

Time

Residential Provider

Date / Time

Date

Time

Residential Staff/Family

Date / Time

Date

Time

Law Enforcement

Date / Time

Date

Time

Children Services

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Staff Signature *

Title *

Date *

Date

Time

Staff Name *

First

Last

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