Indiana Division of Disability, Aging and Rehabilitative Services Bureau of Quality Improvement Services Bureau of Developmental Disabilities Services
INCIDENT REPORT - Confidential
For Use in Reporting Circumstances in 431 IAC 1.1-3-1 (b), 460 IAC 6-9-5 and/or BQIS / BDDS Policy and Procedures
Page of
REV. 04-2004
_____________ _____________
To Submit to BQIS / BDDS CENTRAL Office:
E-Mail to [email protected]
OR
FAX to (317) 233-2320
SECTION I - CONSUMER INFORMATION (Subject # 1)
SSN:
ADDRESS DOB SERVICE TYPE: SGL SL HHA HHC HAB./VOC. LP-ICF/MR COUNTY DD WAIVER A&D WAIVER AUTISM WAIVER SUPP SERVICES WAIVER NAME LAST: FIRST:
CITY
ST GENDER NURSING HOME
ZIP M SCHOOL SDC F
CASE MGMT.
SECTION II - ASSOCIATED PERSON (Subject # 2)
This Section is NOT to be Used For Additional Consumers
SSN (Optional):
ADDRESS AGE RELATIONSHIP TO SUBJECT EMPLOYER
NAME
LAST:
FIRST:
CITY
ST GENDER
ZIP M OTHER F
ACQUAINTANCE CLIENT, OTHER CO-WORKER
EMPLOYER FAMILY-GUARDIAN HOUSEMATE
STRANGER STAFF, HAB/VOC STAFF, RESIDENTIAL
SECTION III - REPORTING PERSON and REPORTING AGENCY
NAME LAST: FIRST: POSITION: PHONE #: EXTENSION:
DATE OF REPORT:
REPORTING AGENCY:
E-MAIL OF REPORTING AGENCY:
INDIVIDUAL SUPERVISING AT TIME OF INCIDENT:
RESPONSIBLE SUPERVISORY PROVIDER:
SECTION IV - INCIDENT INFORMATION
INCIDENT DATE: COMMUNITY SGL SDC COMMUNITY JOB HHA HHC NF TIME: COMMUNITY HAB. HOSPITAL FAC. HAB. ADL LP-ICF/MR WORKSHOP OTHER (Explain) HOME, OWN SCHOOL WHERE OCCURRED? HOME, FAMILY
INDICATE WHICH of the FOLLOWING AGENCIES and/or INDIVIDUALS HAVE BEEN INFORMED
APS/CPS? RES. PROVIDER? HAB/VOC PROVIDER? YES YES YES N/A N/A N/A LEGAL GUARDIAN? BDDS SC? (REQUIRED) CASE MANAGER? YES DATE YES YES YES N/A N/A NAME NAME NAME DATE DATE DATE YES N/A DATE
BQIS CENTRAL OFFICE (REQUIRED)
POLICE?
THIS SECTION IS FOR BQIS / BDDS CENTRAL OFFICE USE ONLY
DATE RECEIVED BY BQIS - BDDS: ALL ACTION COMPLETED ON: Group Home / QMRP Case Manager 7-DAY FOLLOW-UP REQUIRED? YES NO
If YES, Who Completes the Follow-Up:
INCIDENT ID#
BDDS Service Coordinator State Form 51677 (4-04) / BQIS 0001