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Appendix 1 APD OP 10-002

FOR APD USE ONLY

REVIEWED BY:

FORWARDED TO:
Incident #: Medical Case Management
District Behavior Analyst
INCIDENT REPORTING FORM Dep. Director of Operations

Initial Report Follow Up Only

THIS DOCUMENT IS SUBJECT TO CONFIDENTIALITY REQUIREMENTS AND SHOULD BE HANDLED ACCORDINGLY

PERSONS INVOLVED

NAME BIRTHDATE SEX RELATIONSHIP TO APD

DATE OF INCIDENT TIME OF INCIDENT COUNTY

CRITICAL INCIDENT - Must be reported immediately
CONSUMER DEATH SEXUAL MISCONDUCT MEDIA
MISSING CHILD MISSING INCOMPETENT ADULT
REPORTABLE INCIDENT - Must be reported by next business day
ALTERCATION CONSUMER INJURY CONSUMER ARREST
MISSING COMPETENT ADULT SUICIDE ATTEMPT OTHER HOSPITALIZATION MEDICATION ERROR
BAKER ACT EMPLOYEE ARREST

Name of Facility or Provider: Address:

Telephone Number: Date of This Report:

Abuse Hotline Called: No Suppport Coordinatior Notifed Yes

APD Administrator Notified: No Parent/Guardian Notified No
Law Enforcement Notified No DCF Notiified (if in DCF Custory) No

BRIEF DESCRIPTION OF INCIDENT

WHO, WHAT, WHEN, WHERE, HOW, ANY INJURY OR TREATMENT PROVIDED
MORE INFORMATION ON ADDITIONAL PAGES? Yes
Licensed Home ADT/Day Services Supported Living ICF/DD Other

Reporting Person: Phone:

Reviewing Supervisor Phone:

 Appendix 1 APD OP 10-002

Incident #:

FOLLOW-UP MEASURES TAKEN

(This section may be completed at a later date)

DATE AND TYPE OF ORIGINAL INCIDENT

PERSONS INVOLVED

Print Legal Name of Person Date of Birth Sex P or E or W

TYPE OF FOLLOWUP
Behavioral Referral Increase Level of Supervision Staff Training / Retraining

Medical Consultation / Referral Staff Disciplinary Action Medication Review

Hospitalization Other

Briefly describe actions taken for all boxes checked:

Other information: (Corrective Legal, Medical, Disciplinary, or other actions taken since incident was reported:

Report Completed by: Date Completed:

FOR APD USE ONLY: Notified APD Deputy Director for Operations: Date Initials