Fillable Printable Incident Report Form - Ohio
Fillable Printable Incident Report Form - Ohio
Incident Report Form - Ohio
Provider Name & Address:
DODD – Possible or Determined MUI Report Form
Individual’s Name:
DOB:
Address:
City/County:
Date of Incident: Time of Incident: AM/PM
Location of Incident (home in bathroom, at the mall, lunchroom at work):
Description of Incident (Who, What, Where, When):
Injury – Describe Type & Location:
Imm ediate Action to Ensure Health & Welfare of Individuals:
Name of PPI(s):
Relationship to Individual:
Witnesses to Incident:
Others Involved:
Type of Notification
Name/Title
Date/Time
Guardian / Advocate
SSA (required for Independent Providers0
Licensed or Certified Provider
Staff or Family living at the Individual’s home &
responsible for the individual’s care.
LE (Name, Badge Number, Jurisdiction, and contact
information required for Law Enforcement
Enforcement)
CPSA (Name and contact information required for
Children Services)
County Board
Administrator (Required for ICF)
Support Broker (If applicable)
Additional Information/or Administrative Follow-Up:
A. Further Medical Follow-up:
B. Administrative Action:
Signature: Title: Date:
Body Part Injured:
0
Head or Fa ce
0
Neck or Chest
0
Mouth / Teeth
0
Abdomen
0
Hands / Arms
0
Back / Buttocks
0
Feet / Legs
0
Genitals
0
Other
Causes and Contributing Factors:
Preventive measures: (For Provider’s internal use)
Administrator Review: _______________________________ Date: _________________________
