Unusual Incident Report Form

Unusual Incident Report FormProvider Name:Telephone Number:Contact Person:Level of Care:Consumer County of Residence:Consumer Name:Date of Birth:Date of Incident:Time of Incident:(* See list below for fax number)Type of Incident:DeathPotentially Lethal Suicide AttemptHomicide by MemberSexual/Physical Abuse/Neglect Incurred by MemberSerious Physical/Sexual Assault/Neglect by MemberSexual/Physical Abuse Allegation Against ProviderStaff AssaultInjury/Illness While on Provider Site Requiring Medical AttentionInjury/Illness While on Provider Site Requiring HospitalizationMember Injury Due to Restraint/SeclusionElopement from FacilityElopement While on Therapeutic Leave/PassRTF: Consensual Sexual Contact Between PeersRTF to InpatientPolice InvolvementArrest No ArrestJuvenile Detention PlacementFire While on Provider SiteSelf Injuring BehaviorAdverse Effect of Medication Requiring Medical AttentionOtherPlease Describe the Incident in Detail (Use Additional Pages if Needed):Please Describe Actions Taken and/or Expected Follow Up Steps:ChildLine Contacted Police Notified Guardian Contacted OtherReporting Staff's Signature:Date of Report:

Page 2 of 2Instructional Sheet* Please direct the Unusual Incident Report Form to the appropriate fax number as listed below,based upon the Consumer's county of residence.Allegheny 1-888-251-0087Capital 1-866-418-0366Adams, Berks, and York CountiesCarbon/Monroe/Pike Counties 1-866-562-2405Chester 1-888-589-6559North CentralDubois 1-866-294-1142Cameron, Clarion, Clearfield, ElkForest, Jefferson, McKean, Potter,and Warren CountiesMoosic 1-866-558-2618Bradford, Columbia, Montour,Northumberland, Schuylkill, Snyder,Sullivan, Tioga, Union, and Wayne CountiesState College 1-866-562-2406Centre, Huntingdon, Juniata,and Mifflin CountiesNortheast 1-866-284-9184Lackawanna, Luzerne, Susquehanna,and Wyoming Counties