M
1091 Infirmary Road, Elyria, OH 44053

Unusual Incident Report

for MUI only
(who, what, when, where)

Witnesses

(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.)

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.

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

The following MUI notification must be made on the day of occurrence, or discovery, of an MUI incident and include immediate action taken.
< 2022 >
December
SMTuWThFS
    123
45678910
11121314151617
18192021222324
25262728293031