Unusual Incident Report Form
Unusual Incident Report Form
Unusual Incident Report Form
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<strong>Unusual</strong> <strong>Incident</strong> <strong>Report</strong> <strong>Form</strong>Provider Name:Telephone Number:Contact Person:Level of Care:Consumer County of Residence:Consumer Name:Date of Birth:Date of <strong>Incident</strong>:Time of <strong>Incident</strong>:(* See list below for fax number)Type of <strong>Incident</strong>: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 <strong>Incident</strong> in Detail (Use Additional Pages if Needed):Please Describe Actions Taken and/or Expected Follow Up Steps:ChildLine Contacted Police Notified Guardian Contacted Other<strong>Report</strong>ing Staff's Signature:Date of <strong>Report</strong>:
Page 2 of 2Instructional Sheet* Please direct the <strong>Unusual</strong> <strong>Incident</strong> <strong>Report</strong> <strong>Form</strong> 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