​Include as much pertinent information as possible. Outcomes and investigation finding will be added to the report later as the information becomes available.

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1. Reporters (the person calling or writing the report) should always include their name and phone number when making an incident report. Reports should always include a date written and the date/time/location of the incident. If the location of the incident is a specific vendor site, that should be noted.

2. Be sure that the consumer is accurately identified with name, date of birth, UCI number, sex, and diagnosis.

3. Be sure that the vendor name, address and phone number is included in the report.

4. Include the names and phone numbers of witnesses to the incident.

5. For hospitalizations or emergency room visits, include when consumer was seen/admitted, name of the physician who treated the consumer, what treatment was given, when the consumer was discharged, and what orders were given upon discharge.

6. For a medication error/reaction, include the name of the medication, strength, dose, how the error happened, if the M.D. was notified or if the consumer had any adverse effects from the error.

7. For all incident reports, include follow-up activities such as appointments with the consumer’s primary physician, neurologist, psychiatrist, etc., Planning Team meetings, changes to Individual Service Plans/behavior plans, and whether consumer will need to be served by another vendor.

8. For 5150s, be prepared with information regarding the consumer’s past history of behaviors and psychiatric admissions, what behaviors led to the 5150, when consumer is expected to be discharged from the hospital, and whether the consumer will need to be served by another vendor.

9. If the consumer is a victim of a crime, abuse, or rights violation, include a description of the alleged perpetrator. This includes a general physical description, name, and relationship to consumer. If the alleged perpetrator is a staff person, the incident report should include information on the status of the vendor’s investigation. A final report of the investigation outcome should be submitted to SDRC upon completion of the investigation.

10. If the police were involved in the incident, include the name(s), badge number(s), police department, and phone number(s) of the responding police officer(s).

11. Include what action will be taken to prevent similar incidents from occurring in the future.

12. Include what other individuals/agencies were notified of the incident (parents, conservator, guardian, licensing agency, protective services agency, etc.). For agency contacts, include the name of the contact person and their phone number.

13. If the incident is expected to generate media interest, note this in the report.

14. When reporting deaths, you MUST report the following information:

• What were the events leading up to death?

• When was the consumer last in stable health?

• What did the consumer do the day before he or she died?

• Was the consumer’s activity and appetite normal? If tube fed, were feedings being tolerated normally?

• When was the last time the consumer was seen by a physician?

• When was the last time the consumer was checked by a nurse?

• When was the consumer last seen by a staff member before his or her death?

• Was any type of intervention or resuscitation attempted? If so, what was done?

• What is the presumed cause of death?

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SDRC to transmit to DDS within 2 working days from the time anyone in SDRC was notified or has knowledge of the incident.