Valley Mountain Regional Center

VALLEY MOUNTAIN REGIONAL CENTER SPECIAL INCIDENT REPORT

Consumer’s Name Date of Birth UCI Number Date of Report M F

Consumer’s Address Service Coordinator Regional Center

TYPE OF INCIDENT (Reportable Incidents in Bold)

Suspected Abuse/Exploitation (Limited to that Suspected Neglect (Limited to that which has which has occurred while under occurred while under care/supervision of a care/supervision of a vendor.) Check type: vendor.) Check type: Physical Failure to Assist in Personal Hygiene, Sexual Provision of Food, Clothing, Shelter Fiduciary Failure to Prevent Malnutrition or Emotional/Mental Dehydration Physical and/or Chemical Restraint Failure to Provide Medical Care Failure to Protect from Health & Safety Serious Injury/Accident Which Occurs While Hazards the Consumer is Under the Care and Exercise a degree of care that a Supervision of Any Vendor and Results in reasonable person would exercise in a One or More of the Following (Check type): position of having the care and custody Lacerations requiring sutures or of an elder or a dependent adult. staples Puncture wounds requiring medical Any Unplanned or Unscheduled treatment beyond first aid Hospitalization Due to the Following Fractures Conditions. Check type: Dislocations Respiratory illness Bites that break the skin and require Seizure-related medical treatment beyond first aid Cardiac related Internal bleeding Internal infections Any medication errors Diabetes/Diabetes related Medication reactions that require complications medical treatment beyond first aid. Wound/skin care Burns that require medical treatment Nutritional deficiencies beyond first aid Involuntary psychiatric admission

Victim of Crime (Regardless of consumer’s Missing Person (Complete only when living arrangement or perpetrator.) Check reported to law enforcement and if consumer type: was under care/supervision of a vendor.) Personal Robbery Aggravated assault  Death (Regardless of living arrangement, Rape cause or perpetrator) Burglary Larceny Other (specify)

Supplemental/Optional Reporting Serious Injury/Accident Which Occurs While the Other Check type: Consumer is Under the Care and Supervision of Violation of Rights Any Vendor and Results in One or More of the Pregnancy Following: Check type: Disease outbreak Injury-Accident Fire Consumer’s Name: Page 2 of 3 UCI#: Date of Report:

Injury-Unknown origin Suicide attempt Injury from seizure Threatened suicide Injury from another consumer Medical emergency Injury from behavior episode Property damage Other sexual incident—Not rape Aggression Displayed by Consumer. Check type: Unauthorized absence–law enforcement Aggressive act to self not notified Aggressive act to another consumer Other: Aggressive act to staff Aggressive act to family/visitor

Incident date  Definitive Time of incident  Definitive  Approximate  Approximate

Date incident reported to Regional Center and to Medical Care/Treatment Required? whom  Yes  No

Relationship of alleged perpetrator to consumer Another Consumer Unknown Self Vendor or Employee of Vendor Non-Vendor or Employee of Non-Vendor Relative/Family Member

Individual known to consumer (Not a provider or another consumer) Not applicable Incident location Acute hospital–not ER Job site Day program Acute hospital–ER Out of home respite Consumer’s Day care/ Intervention program Community setting residence Psychiatric treatment center Home of family Hospice SNF In transit Jail or related setting Other Subacute or pediatric subacute Public school Rehabilitation facility

Party/Entity responsible for consumer at time of incident Vendor Name: Name: Vendor Type: Vendor Number: Address:

Self/Spouse Residential City/Zip:

Parent/Family Day Program Telephone:

Other:

Other agencies notified Consumer’s Name: Page 3 of 3 UCI#: Date of Report:

Community Care Licensing DHS Licensing & Certification

Child Protective Services Adult Protective Services

Parent/Guardian/Conservator Long-Term Care Ombudsman

Police/Law Enforcement Other:

Coroner Other:

Description of incident

Specific preventative action taken or planned by the vendor:

Reporting Person’s Name:

Signature: Date:

(SIR template – revised 09/18/2007) ej