Form DD 191 FF – Fill Out and Use This PDF

The DD-191-FF form is a critical tool used by the Arizona Department of Economic Security's Division of Developmental Disabilities for incident reporting. This form ensures that all necessary details concerning an incident, including before, during, and after, are thoroughly documented. Providers and staff can use this form to report incidents, aiming to gather all pertinent information which could be vital for implementing preventive measures or corrective actions. Ready to ensure accountability and enhance safety measures? Click the button below to fill out the form.

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Form DD 191 FF PDF Details

The DD-191-FF form, issued by the Arizona Department of Economic Security's Division of Developmental Disabilities, serves as a comprehensive incident report designed to capture all relevant details about occurrences involving individuals in care. It is a crucial document for both division staff and providers, ensuring accurate and complete recording of any incidents. This form requires the reporter to include information about the individual involved, such as their name, birthdate, and address, in addition to detailed accounts of the incident, including what happened before, during, and what could have potentially prevented the incident. The second page of the form focuses on the aftermath, documenting the type of medical intervention received, locations, and notifications to relevant parties including parents or guardians, support coordinators, and even law enforcement if necessary. Completion of this form is essential not just for immediate response and corrective actions but also for policy development and preventive measures. It's a tool to ensure transparency, accountability, and a commitment to the safety and well-being of those under the care of the Division of Developmental Disabilities, while also adhering to various legal and civil rights protections such as the Americans with Disabilities Act and the Civil Rights Act.

Question	Answer
Form Name	Form DD 191 FF
Form Length	3 pages
Fillable?	Yes
Fillable fields	46
Avg. time to fill out	10 min
Other names	DDD incident reporting AZ, AZ DDD clients incident report format, DD-191-FF

Form Preview Example

DD-191-FF (5-10)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

INCIDENT REPORT

Please Print

Confidential Information

•Division staff may use this form to ensure all pertinent incident information is gathered.

•Providers may use this form or write all pertinent incident information on a separate report to the Division.

INDIVIDUAL'S NAME (Last, First, M.I.)		FOCUS ID NO.			BIRTHDATE

INDIVIDUAL'S ADDRESS (No., Street, City, State, ZIP)						FOSTER CARE
						Yes	No
PROVIDER NAME AT TIME OF INCIDENT (Qualified Vendor, Individual Independent Provider, Provider Site Name)

NAME AND LOCATION OF INCIDENT (Site Name, No., Street, City State, ZIP)			DATE OF INCIDENT				TIME OF INCIDENT
							PM AM

STAFF/WITNESS(ES) INVOLVED IN INCIDENT (Last, First, M.I.)	PHONE NUMBER			IMMEDIATE SUPERVISOR
1.	(	)					N/A

	PHONE NUMBER			IMMEDIATE SUPERVISOR
2.	(	)					N/A

DESCRIBE INCIDENT THOROUGHLY. (What happened before, during and after the incident. Include all known facts, causes of injury and emergency measures, if applicable. Write clearly, objectively and in order of occurrence, without reference to the writer's opinion.)

WHAT HAPPENED BEFORE THE INCIDENT?

WHAT HAPPENED DURING THE INCIDENT?

WHAT COULD HAVE PREVENTED THE INCIDENT?

Form is continued on reverse (page 2)

DD-191-FF (5-10) - PAGE 2

INDIVIDUAL'S NAME (Last, First, M.I.)

DATE OF INCIDENT

TYPE OF MEDICAL INTERVENTION (Doctor's visit, urgent care, emergency room, hospitalization)

LOCATION OF MEDICAL INTERVENTION (Site location and address)

NOTIFICATIONS

SERIOUS INCIDENTS, as described in the Division's Policy and Procedures Manual Administrative Directive 76, are to be reported and written as soon as possible, but no later than 24 hours after the incident.

ALL OTHER INCIDENTS, as described in the Directive, must be reported to the District office by the close of the next business day following the incident.

PARENT/GUARDIAN NOTIFIED (If Yes, name of person notified. If No, explain why)

NOTIFIED BY WHOM (Last First, M.I.)

DATE/TIME OF NOTIFICATION

Yes	No	N/A		AM	PM

SUPPORT COORDINATOR NOTIFIED
Yes	No	N/A		AM	PM

CHILD/ADULT PROTECTIVE SERVICES NOTIFIED
Yes	No	N/A		AM	PM

TRIBAL SOCIAL SERVICES NOTIFIED
Yes	No	N/A		AM	PM

POLICE NOTIFIED
Yes	No	N/A		AM	PM

PRINT NAME OF PERSON COMPLETING THIS FORM			SIGNATURE OF PERSON COMPLETING FORM	DATE

CORRECTIVE ACTION/COMMENTS

WHAT STEPS ARE BEING TAKEN TO PREVENT THIS FROM HAPPENING AGAIN?

PRINT SUPERVISOR'S NAME

SIGNATURE OF SUPERVISOR

DATE

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.

How to Edit Form DD 191 FF Online for Free

The Arizona DD-191-FF form maintains complete records of events, including accidents, injuries, or any significant occurrences that need review or further action. Here's a detailed guide on filling out this document.

1. Fill in Personal Information

Begin by writing the individual's name, Focus ID number, birth date, and complete address.

2. Incident Details

Provide the name and location of the incident, including the site name and address. Specify the date and time of the incident, choosing AM or PM as appropriate.

3. Provider Information

If the incident occurred under the supervision of a provider, state the provider's name at the time of the incident. This could be a qualified vendor, an individual independent provider, or the name of the provider site.

Form is continued on reverse page, Form is continued on reverse page, and Form is continued on reverse page inside VII

4. Staff and Witness Information

List the names of any staff or witnesses involved, along with their phone numbers. If applicable, include their immediate supervisors.

Yes, Serious incidents as described in, and DATE OF INCIDENT inside VII

5. Describe the Incident

Detail what happened before, during, and after the incident. Be clear, objective, and chronological in your description. Avoid personal opinions to maintain the report's objectivity.

6. Medical Intervention

If medical intervention was necessary, note the type (e.g., doctor's visit, hospitalization) and the location of the medical intervention.

7. Notifications

Record details about notifications made to parents or guardians, support coordinators, and other relevant parties such as Child/Adult Protective Services or police. Specify who made the notification, the date, and time.

8. Completing the Form

The person completing the form must print their name, sign, and date it. If corrective actions are suggested to prevent future incidents, these should be described under the "Corrective Action/Comments" section. Finally, the supervisor should print their name, sign, and date the form to confirm the information and the follow-up actions.