Reportable EventsReportable Events Please Fill out This Form: Date of Incident * Event Categories (Select each that apply) * Dangerous Situation Death Emergency Department Visit Emergency Restraint Suicide Threat Rights Violation Serious Injury Suicide Attempt Physical Assault/Altercation Transportation Accident Property Damage Elopement Physical Plant Disaster Law Enforcement Intervention Lost or Missing Person Medication Error Hospital Admission – Planned/Unplanned Medical Treatment Other Than HospitalPerson InformationName * Name First Name First Name Last Name Last Name Date of Birth * Facility Program * Incident InformationEvent Start Time * 121234567891011 : 000510152025303540455055 AMPMEvent End Time * 121234567891011 : 000510152025303540455055 AMPM Date Reported to DHHS * DHHS Person Reported To * DHHS Person Reported To First Name First Name Last Name Last NameDepartment Reported To * DS Caseworker Crisis DS Regional Supervisor/PA Incident Data Specialist (EIS entry only) Program Type * DS Home SupportsDS Community SupportsDS Employment SupportDS CrisisOther (Specify) Short Description of Event * Reporter Name * Reporter Name First Name First Name Last Name Last Name Phone Number * Reporter Type * Consumer Caseworker Family Member Guardian DS Provider Direct Care DS Crisis Team DS APS Intake Unit DS Provider/Manager/Supervisor Other (Specify)Reporter Role Participant in EventWitness Method of Reporting CallEmail Agency Contact Information Person/Agency Responsible For Content And Reporting to DHHS * Agency StaffAgency SupervisorAgency ManagerAgency Director Name * Name First Name First Name Last Name Last Name Email * Phone Number * Provider/Agency Address Provider/Agency Address Provider/Agency Address Provider/Agency Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Information Received Date * Time Information Received * 121234567891011 : 0030 AMPMWorker Details Was Worker(s) involved in event? * YesNoUnknown Worker Type * Direct Support Professional (DSP)SupervisorManagerDirectorOther Role * ParticipantWitnessOther Was Another Person(s) involved in event? * YesNoUnknown Worker Type Direct Service Specialist (DSP) Role Participant Family/Guardian Notifications Guardian Notified * YesNoNo Guardian Guardian Name Guardian Name First Name First Name Last Name Last Name Phone Number Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Submit If you are human, leave this field blank.
