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Auglaize DD Incident Form
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* Indicates required question
Email
*
Your email
Provider Name & Address:
*
Your answer
Provider's Phone Number:
*
Your answer
Individual's Name:
*
Your answer
Individual's Date of Birth:
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MM
/
DD
/
YYYY
Individual's Address:
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Your answer
Date of Incident:
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MM
/
DD
/
YYYY
Time of Incident:
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Time
:
AM
PM
Location of Incident (eg: at home, at work, at the mall, etc.):
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Your answer
Description of Incident (Who, What, Where, When):
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Your answer
Injury (Describe Type and Location):
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Your answer
Body Part Injured:
*
Head or Face
Mouth/Teeth
Hands/Arms
Feet/Legs
Neck or Chest
Abdomen
Back/Buttocks
Genitals
Required
Immediate Action to Ensure Health and Welfare of Individual(s):
*
Your answer
Name of Primary Person(s) involved (PPIs):
*
Your answer
Relationship to Individual:
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Your answer
Witnesses to Individual:
*
Your answer
Others Involved:
*
Your answer
Type of Notification:
NOTE: Please choose who else you have notified about this incident.
*
Guardian/Advocate
SSA (Required for Independent Providers)
Licensed or Certified Provider
Staff of family living at individual's home and responsible for their care
Law Enforcement (Name, Badge Number, Jurisdiction and contact information required for Law Enforcement)
Children Protection Services Agency (name and contact information required for Children Services)
County Board
Administrator (Required for ICF)
Support Broker (if applicable)
Required
Name/Title and Date/Time of all persons notified:
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Your answer
Reporter's Name and Phone Number:
*
Your answer
Date Reporter Discovered the Incident:
*
MM
/
DD
/
YYYY
Time Reporter Discovered the Incident:
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Time
:
AM
PM
Was Further Medical Follow-Up Provided? (If yes, please explain):
*
Your answer
Was Additional Administrative Action Given? (If yes, please explain):
*
Your answer
Causes and Contributing Factors:
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Your answer
Preventative Measures:
*
Your answer
Signature (By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.)
*
Your answer
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