UI Monthly Report Log for Independent Providers

All information needed to complete this form should come from the corresponding Unusual Incident Report that has already been completed.

Independent Provider Name *

Provider Address *

Email *

Month *

Year *

Providing services for the following consumers *

Name *

First

Last

Date / Time *

Date

Time

Injury *

Description of Incident (Explain Risk of Harm) *

Immediate Action Taken to Ensure Health & Welfare *

Causes & Contributing Factors *

Prevention Plan *

Reviewed By *

Date *

Trends and Patterns Identified? *

Trends and Patterns Addressed? *

(If YES, please complete section below.)

Action taken to address identified Patterns and Trends

Submitted by *

Date *

Signature *

By checking this box, I agree that my printed name I have entered above, will be the legal electronic representation of my signature. *