Dc Unusual Incident Report Form PDF Details

Are you familiar with the unusual incident report form? If not, you should become acquainted with it sooner rather than later. This document is used to report any incidents that occur in your place of business that are deemed as "unusual." What makes an incident unusual? That's a good question, and one that isn't always easy to answer. Ultimately, it's up to the person completing the form to decide what constitutes an unusual incident. That said, there are some general guidelines that can be followed. For example, anything out of the ordinary or unexpected would likely be considered unusual. So if you experience something weird or strange at work, be sure to fill out an unusual incident report form! Doing so can help ensure that everyone is aware of what

QuestionAnswer
Form NameDc Unusual Incident Report Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesosse uir form, osse unusual incident, dhs incident report, dc unusual incident report

Form Preview Example

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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Step 2: This tool allows you to work with PDF forms in various ways. Change it with personalized text, correct what's originally in the document, and place in a signature - all readily available!

This document will need you to enter specific information; to guarantee accuracy, be sure to take into account the subsequent guidelines:

1. To begin with, when filling in the dc unusual incident report form, start in the form section that features the subsequent blank fields:

osse unusual report conclusion process shown (stage 1)

2. Right after finishing the previous step, go on to the subsequent step and complete all required particulars in these fields - PERSON REPORTING INCIDENT TO CID, FACILITY NAME, TITLEPOSITION, ADDRESS, Home Telephone Number with area, DIRECTOR OWNER, DATE REPORTED, TIME REPORTED, OFFICE, CELL, PART II INCIDENT INFORMATION, Date of Incident, Time of Incident, Date of Report, and Type of Incident accident injury.

Filling out section 2 in osse unusual report

You can potentially make errors when completing your Date of Incident, therefore make sure to go through it again before you finalize the form.

3. Within this step, check out Witness NAME Last Middle a Home, First, Witness NAME Last, Middle a Home Telephone Number, First, First, Witness NAME Last, Middle a Home Telephone Number, Middle a Home Telephone Number, First, and Additional witnesses attach a. Each of these will need to be filled out with utmost accuracy.

Part no. 3 of filling in osse unusual report

4. It's time to fill in this fourth segment! Here you will have these PART IV WHAT ACTIONS WERE TAKEN fields to fill out.

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

5. As a final point, this final subsection is what you need to finish before submitting the document. The fields you're looking at are the next: Signature.

osse unusual report conclusion process outlined (stage 5)

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