Incident Report to DDA - Washington State



Incident InformationINCIDENT DATE FORMTEXT ?????INCIDENT START TIME FORMTEXT ?????INCIDENT END TIME FORMTEXT ?????PROVIDER NAME FORMTEXT ?????DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)Incident Report to DDAPersons Involved (Per your agency policy, you may use full names or initials for other involved clients.)LAST NAMEFIRST NAMEINCIDENT ROLEPERSON TYPE FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item. FORMTEXT ????? FORMTEXT ?????Choose an item.Choose an item.Incident DetailsANTECEDENT (WHAT HAPPENED BEFORE / LEADING UP TO THE INCIDENT)INCIDENT DESCRIPTIONSTAFF RESPONSE (WHAT DID STAFF DO IMMEDIATELY FOLLOWING / AS A RESULT OF THE INCIDENT)AS A RESULT OF THE INCIDENT, CHECK ACTIONS TAKEN / PLANNED WITHIN NEXT SEVEN (7) DAYS. FORMCHECKBOX Client relocation FORMCHECKBOX IISP updated FORMCHECKBOX Provider initiating investigation FORMCHECKBOX CSCP updated FORMCHECKBOX Increased supervision FORMCHECKBOX Staff reassigned FORMCHECKBOX Doctor / Nurse / Pharmacy contacted FORMCHECKBOX Medical assessment / treatment FORMCHECKBOX Staff reassigned – no client contact FORMCHECKBOX FA / PBSP written / updated FORMCHECKBOX Mental health facility admission FORMCHECKBOX Staff terminated FORMCHECKBOX Hospital admission FORMCHECKBOX Mental health referral FORMCHECKBOX Staff voluntarily resigned FORMCHECKBOX Other staff action: FORMTEXT ?????DESCRIBE HEALTH AND WELFARE ACTIONS TAKEN OR PLANNED AS RESULT OF INCIDENTWere there any client injuries that required treatment beyond First Aid? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe any injuries as a result of this incident, who was injured, and type and location of injury:Is abuse, neglect, personal or financial exploitation, abandonment, or improper restraint suspected? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain briefly below.Notifications by ProviderDATE NOTIFIEDPERSON / ENTITY NOTIFIEDCONFIRMATION / CASE NUMBER FORMCHECKBOX DDA notification as required by DDA policy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Medical professional FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Guardian / Legal Representative FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX CRU / RCS / APS / CPS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Law enforcement FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Department of Health FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Emergency medical / fire FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Coroner / Medical Examiner FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX County Staff FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Person Submitting ReportNAME FORMTEXT ?????TITLE FORMTEXT ?????DATE SUBMITTED FORMTEXT ????? ................
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