Form06MP046E(DDS-46).docVIP

Staff completes this form to report any critical and non-critical incident involving a person who receives Developmental Disabilities Services Division (DDSD) services. Name Date of report Provider agency Incident location Date of incident observed discovered Time of incident a.m. p.m. Critical incidents, check all that apply. Notify staff per OAC 340:100-3-34. Any critical incident requires immediate verbal notification to DDSD case manager or, if incident occurs after regular working hours, DDSD on-call staff. Suspected abuse, neglect, or exploitation, notified: Adult Protective Services Office of Client Advocacy Child Welfare Services Threat of suicide Attempt of suicide Death Unplanned hospital admission: psychiatric facility result of medication error transport by ambulance Medication event resulting in need for emergency medical treatment Law enforcement involvement: criminal behavioral Loss of property more than $500: fire natural disaster theft behavioral destruction Missing person: lost in danger community protection issue police notified Unusual or significant incident that may attract media attention Use of highly restrictive procedure: p.r.n. medication for behavioral control,  medication time dose physical hold, amount of time in hold authorized in Protective Intervention Plan (PIP) injury other, describe Non-critical incidents, check all that apply. Injury or Unplanned health-related event: treatment not required treatment, consultation, or both by physician treatment by other than physician emergency room visit transport by ambulance Physical aggression toward: self, self–injurious behavior (SIB) staff others Name Date of incident Time of incident a.m. p.m. Fire setting Deliberate harm to an animal Loss of property less than $500: fire natural disaster theft behavioral destruction Vehicle accident Suspension, removal, or termination of persons p