Unusual Incident Report

Individual’s Name *

First

Last

Individual's Address

Address Line 1

Address Line 2

City

State

Zip Code

Provider Contact Person

First

Last

Phone Number

Date and Time Incident Occurred

Date

Time

Date and Time Incident Discovered *

Date

Time

Specific Location Where Incident Occurred

Date and Time Incident Reported *

Date

Time

Supervisor

Date and Time Reported to IA

Date

Time

for MUI only

Description of Incident *

(who, what, when, where)

Witnesses

Name

First

Last

Title

Phone

Name

First

Last

Title

Phone

Name and Relationship of Primary Person(s) Involved and their relationship to individual

(Primary Person Involved means the person alleged to have committed or to have been responsible for abuse, accidental or suspicious death, exploitation, failure to report, misappropriation, neglect, prohibited sexual relations, or rights code violation.)

Did Injury Occur

Yes, an injury occured
No, an injury didn’t occur

Assessment Completed by Whom?

First

Last

Title

Date

Describe immediate action taken to ensure health and welfare of the individuals involved and any at-risk individuals *

Describe any further medical follow-up required

REQUIREMENTS FOR IMMEDIATE REPORTING TO INVESTIGATE AGENTS (IAs)

Alleged Abuse, Neglect, Exploitation, Misappropriation, Peer-to-Peer Acts, Prohibited Sexual Relations, Accidental or Suspicious Death, or Media Inquiries about an MUI must be verbally reported to an IA within 4 hours of the discovery of the incident.

REQUIRED NOTIFICATIONS FOR A UI

UI notification to other providers of services as necessary to ensure continuity of care and support for the individual.

Provider Name

Title

Date / Time

Date

Time

Provider Name

Title

Date / Time

Date

Time

Provider Name

Title

Date / Time

Date

Time

Independent providers must notify guardian/identified other and send completed UI Report to SSA by the next working day after discovery of UI.

Guardian/Identified Other

Date / Time

Date

Time

SSA

Date / Time

Date

Time

REQUIRED NOTIFICATIONS FOR A POTENTIAL OR IDENTIFIED MUI

The following MUI notification must be made on the day of occurrence, or discovery, of an MUI incident and include immediate action taken.

Guardian/Identified Other

Date / Time

Date

Time

SSA

Date / Time

Date

Time

Residential Provider

Date / Time

Date

Time

Residential Staff/Family

Date / Time

Date

Time

Law Enforcement

Date / Time

Date

Time

Children Services

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Other Provider

Date / Time

Date

Time

Person Completing the Form *

First

Last

Title *

Date *

Date

Time

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Unusual Incident Report

Witnesses

REQUIREMENTS FOR IMMEDIATE REPORTING TO INVESTIGATE AGENTS (IAs)

REQUIRED NOTIFICATIONS FOR A UI

Independent providers must notify guardian/identified other and send completed UI Report to SSA by the next working day after discovery of UI.

REQUIRED NOTIFICATIONS FOR A POTENTIAL OR IDENTIFIED MUI

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