DC Unusual Incident Report Form – Fill Out and Use This PDF

The DC Unusual Incident Report form is a crucial document used by the Division of Early Childhood Education to ensure the safety and well-being of children in child care settings. This form is intended to capture any event that deviates from the norm and could potentially harm children, including incidents like accidents, abuse, or facility issues. For those responsible for children's care, knowing how to complete this form accurately and promptly is essential.

To ensure the safety and well-being of children in your care, fill out the DC Unusual Incident Report form by clicking the button below.

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Dc Unusual Incident Report Form PDF Details

In child care facilities across Washington, DC, ensuring the health, safety, and well-being of children is paramount. To address any deviations from normal operations that could negatively impact children, the Division of Early Childhood Education has established a comprehensive reporting process through the Unusual Incident Report (UIR) form. This form serves as a crucial tool for documenting incidents that are out of the ordinary, ranging from accidents and injuries to allegations of abuse or serious facility issues. It is meticulously designed to capture detailed information about the incident, including the individuals involved, the nature and details of the event, actions taken in response, and measures implemented to prevent future occurrences. With a dedicated hotline and email for submissions, the form ensures timely communication with the Compliance and Integrity Division (CID), underscoring the commitment to maintaining a safe and nurturing environment for children. By requiring a signature from the person reporting the incident, the form also upholds the integrity and accountability of the reporting process. The UIR form embodies an essential administrative protocol, reinforcing the collective responsibility to safeguard the welfare of children in care facilities throughout the district.

Question	Answer
Form Name	DC Unusual Incident Report Form
Form Length	3 pages
Fillable?	Yes
Fillable fields	44
Avg. time to fill out	10 min
Other names	OSSE UIR form, OSSE unusual incident, DHS incident report, DC unusual incident report

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DIVISION OF EARLY CHILDHOOD EDUCATION

INSTRUCTIONS FOR COMPLETING

THE UNUSUAL INCIDENT REPORT (UIR) FORM

Completed forms should be faxed to the Compliance and Integrity Division (CID) at 202 -727-7295.

Unusual incidents can also be reported via the dedicated hotline at 202-727-2993 or emailed to OSSE.ChildcareComplaints@dc.gov

Definition: An “Unusual Incident” is any event that is not ordinary to the regular or established procedure that may adversely affect the health, safety or well being of any child or children in the child care facility.

Examples include, but are not limited to: accident or injury; physical, sexual, or verbal abuse of a child by staff or other child(ren); staff negligence; communicable disease occurrence; facility / property issues, including building security, theft, arson, bomb, fire threats, false alarms; and request for information or access to the participation from the press, attorneys, government officials outside OSSE/ECE; or persons other than those authorized by the parent.

UIR Forms must be filled out completely and accurately.

PART I – REPORTING INDIVIDUAL - Enter required information

PART II – INCIDENT INFORMATION - Enter required information

NOTE: Upon completion of item #7, if there are no other persons involved and no witnesses, skip to PART III and complete the details of the incident.

PART III – DESCRIPTION AND DETAILS OF INCIDENT

Enter complete information on who was involved, what occurred, where the incident occurred and how it occurred. List first and last names of everyone involved.

PART IV – WHAT ACTIONS WERE TAKEN AND BY WHOM

Enter any actions that were taken in response to the incident, such as police or family notified, medical treatment provided, etc. Also indicate corrective measures taken to prevent reoccurrence, including administrative, managerial or disciplinary actions taken and by whom.

SIGNATURE REQUIREMENT

The reporting person’s signature and date of signing is required.

COMPLIANCE AND

INTEGRITY DIVISION

PHONE: (202) 727-2993

FAX: (202) 727-7295

UNUSUAL INCIDENT REPORT FORM

PART I - REPORTED BY

MAILING ADDRESS:

810 First Street, NE

4th Floor

Washington, DC 20002

1. PERSON REPORTING INCIDENT TO CID

FACILITY NAME:

TITLE/POSITION

ADDRESS

Home Telephone Number (with area code):

DIRECTOR/ OWNER

DATE REPORTED

TIME REPORTED

OFFICE #

CELL #

PART II -INCIDENT INFORMATION

2. Date of Incident:			3. Time of Incident:		4. Date of Report:

5. Type of Incident:
(accident, injury or unusual occurrence)
6. Incident Location Address:

7. Person Involved (Adult		Child	) Age ____	8. Person Involved (Adult		Child	) Age______
NAME:_____________________________________				NAME:______________________________________
LAST	FIRST		MIDDLE	LAST	FIRST		MIDDLE
Home Telephone Number (with area code):				Home Telephone Number (with area code):

9. Person Involved (Adult		Child	)	10. Person Involved (Adult		Child	)
NAME:______________________________________				NAME:______________________________________
LAST	FIRST		MIDDLE	LAST	FIRST		MIDDLE
Home Telephone Number (with area code):				Home Telephone Number (with area code):

Additional persons involved attach a separate sheet.

11. Witness 1:				12. Witness 2:
NAME:___________________________________				NAME:_______________________________________
LAST	FIRST		MIDDLE	LAST	FIRST		MIDDLE
11a. Home Telephone Number (with area code):				12a. Home Telephone Number (with area code):

13. Witness 3:				14. Witness 4:
NAME:______________________________________				NAME:______________________________________
LAST	FIRST		MIDDLE	LAST	FIRST		MIDDLE
13a. Home Telephone Number (with area code):				14a. Home Telephone Number (with area code):

Additional witnesses attach a separate sheet.

PART III -DESCRIPTION AND DETAILS OF INCIDENT

15. Who, What, Where and How: (If necessary, attach a separate sheet for additional information)

_____________________________________________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

PART IV - WHAT ACTIONS WERE TAKEN AND BY WHOM

_____________________________________________________________________________________________

Signature _________________________________________

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osse unusual report conclusion process shown (stage 1)

1. Reporting Individual Information

Fill in your details as the reporter: name, title, facility name, and contact information, including home, office, and cell phone numbers. Note the date and time when the incident was reported.

2. Incident Information

Detail the incident by noting the date, time, type (e.g., accident, injury), and location. Include names, ages, and contact information of all involved parties, adding extra sheets if necessary.

Filling out section 2 in osse unusual report

3. Description and Details of Incident

Describe the incident comprehensively. Specify who was involved, what exactly happened, where it occurred, and how the events unfolded.

Part no. 3 of filling in osse unusual report

4. Actions Taken in Response

List immediate actions taken following the incident, such as notifying authorities or medical interventions. Document any preventive measures implemented to avoid future incidents.

PART IV WHAT ACTIONS WERE TAKEN, PART IV WHAT ACTIONS WERE TAKEN, and PART IV WHAT ACTIONS WERE TAKEN inside osse unusual report

5. Signature Requirement

Sign and date the form to confirm the accuracy and timeliness of the information reported.

osse unusual report conclusion process outlined (stage 5)

6. Submission of the Form

Fax the completed form to the Compliance and Integrity Division, or report via the dedicated hotline or email. Ensure all provided instructions for submission are followed.

DC Unusual Incident Report Form – Fill Out and Use This PDF

Dc Unusual Incident Report Form PDF Details

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