Unusual Incident Report Form All Counties
Unusual Incident Report Form All Counties
Unusual Incident Report Form All Counties
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Unusual</strong> <strong>Incident</strong> <strong>Report</strong> <strong>Form</strong><br />
<strong>All</strong> <strong>Counties</strong><br />
Provider Name:<br />
Telephone Number:<br />
Contact Person:<br />
Level of Care:<br />
Consumer County of Residence:<br />
Consumer Name:<br />
MA ID #:<br />
Date of Birth:<br />
Date of <strong>Incident</strong>:<br />
Time of <strong>Incident</strong>:<br />
(* See list below for fax number)<br />
Type of <strong>Incident</strong>:<br />
Death<br />
Potentially Lethal Suicide Attempt<br />
Homicide by Member<br />
Sexual/Physical Abuse/Neglect Incurred by Member<br />
Elopement from Facility<br />
Elopement While on Therapeutic Leave/Pass<br />
RTF: Consensual Sexual Contact Between Peers<br />
RTF to Inpatient<br />
Serious Physical/Sexual Assault/Neglect by Member<br />
Police Involvement -<br />
Arrest<br />
No Arrest<br />
Sexual/Physical Abuse <strong>All</strong>egation Against Provider<br />
Staff Assault<br />
Injury/Illness While on Provider Site Requiring Medical Attention<br />
Injury/Illness While on Provider Site Requiring Hospitalization<br />
Member Injury Due to Restraint/Seclusion<br />
Juvenile Detention Placement<br />
Fire While on Provider Site<br />
Self Injuring Behavior<br />
Adverse Effect of Medication Requiring Medical Attention<br />
Other<br />
Please Describe the <strong>Incident</strong> in Detail (Use Additional Pages if Needed):<br />
Please Describe Actions Taken and/or Expected Follow Up Steps:<br />
ChildLine Contacted Police Notified Guardian Contacted Other<br />
<strong>Report</strong>ing Staff's Signature:<br />
Date of <strong>Report</strong>:
Page 2 of 2<br />
Instructional Sheet<br />
* Please direct the <strong>Unusual</strong> <strong>Incident</strong> <strong>Report</strong> <strong>Form</strong> to the appropriate fax number as listed below,<br />
based upon the Consumer's county of residence.<br />
<strong>All</strong>egheny 1-888-251-0087<br />
Blair 1-855-480-7029<br />
Capital 1-866-418-0366<br />
Adams, Berks, and York <strong>Counties</strong><br />
Carbon/Monroe/Pike <strong>Counties</strong> 1-866-562-2405<br />
Chester 1-888-589-6559<br />
Erie 1-855-892-8495<br />
Lycoming/Clinton 1-855-346-7318<br />
North Central<br />
Dubois 1-866-294-1142<br />
Cameron, Clarion, Clearfield, Elk<br />
Forest, Jefferson, McKean, Potter,<br />
and Warren <strong>Counties</strong><br />
Moosic 1-866-558-2618<br />
Bradford, Columbia, Montour,<br />
Northumberland, Schuylkill, Snyder,<br />
Sullivan, Tioga, Union, and Wayne <strong>Counties</strong><br />
Pittsburgh 1-866-294-3935<br />
State College 1-866-562-2406<br />
Centre, Huntingdon, Juniata,<br />
and Mifflin <strong>Counties</strong><br />
Northeast 1-866-284-9184<br />
Lackawanna, Luzerne, Susquehanna,<br />
and Wyoming <strong>Counties</strong>
Change language