HomeMy WebLinkAboutAttachment SMiAWDADE
INCIDENT REPORT
IDENTIFYING INFORMATION
ATTACHMENT S
Reporting Party Phone # Date of Incident / / Time of Incident _
Reporting Party Name
Contract Provider Name
Program Name
Provider Location
Specific Program: (check all that apply)
❑ HT ❑ Primary Care ❑ SHP ❑ Emergency ❑ Challenge
Specific lacafion/address where incident occurred:
TYPE OF INCIDENT
❑ ALTERCATION
❑ CLIENT INJURY OR ILLNESS
❑ SEKUAL .BATTERY
❑ PROPERTYDAA1MGE
❑ CLIENT DEATH
13 THEFT
❑ SUICIDE ATTEMPT
❑ OTHER INCIDENT
Specify
PARTICIPANT (S) / WITNESS (ES)
(Please mark W or P for either Witness or Participant)
LAST NAME, FIRST IDENTIFIER # CLIENT
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am/pm
EMPLOYEE OTHER W / P
❑ ❑ _
❑ ❑ _
❑ ❑
MIAMI MDE
L=
Definitions of Reportable Incidents
a. Altercation. A physical confrontation occurring between a client and employee or
two or more clients at the time services are being rendered, or when a client is in the
physical custody of the department, which results in one or more clients or employees
receiving medical treatment by a licensed health care professional.
b. Client Death. A person whose life terminates due to or allegedly due to an accident,
act of abuse, neglect or other incident occurring while in the presence of an employee,
in Homeless Trust contracted program facility.
c. Client Injury or Illness. A medical condition of a client requiring medical treatment
by a licensed health care professional sustained or allegedly sustained due to an
accident, act of abuse, neglect or other incident occurring while in the presence of an
employee, in a Homeless Trust contracted program.
d. Other Incident. An unusual occurrence or circumstance initiated by something other
than natural causes or out of the ordinary such as a tornado, kidnapping, riot, or
hostage situation, which jeopardizes the health, safety and welfare of clients.
Sexual Battery. An allegation of sexual battery by a client on a client, employee on a
client, or client on an employee as evidenced by medical evidence or law enforcement
involvement.
f Suicide Att. An act which clearly reflects the physical attempt by a client to
cause his or her own death while in the physical custody of the department or a
departmental contracted or certified provider, which results in bodily injury requiring
medical treatment by a licensed health care professional.
Property Damage
An incident involving damage to property procured with Homeless Trust funding.
Print Name of Person Submitting Report Signature
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