Form Dd 191 Ff PDF Details

Form Dd 191 Ff is a document that needs to be filed with the Internal Revenue Service in order to request an extension of time to file your federal income tax return. This document is used by individuals or businesses who need more time to complete their tax return, and can be filed online or by mail. The extension will give you an additional six months to submit your return. Note that an extension of time to file does not extend the time for payment of taxes owed - all taxes must be paid by the original due date of the return. So if you are expecting a refund, you will still receive it within the six-month extension period. Filing for an extension should not be taken lightly, as there are penalties for late filing. But if you need more time, Form Dd 191 Ff is the way to go.

QuestionAnswer
Form NameForm Dd 191 Ff
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesddd incident reporting az, az ddd clients incident report format, DD-191-FF, NOTIFICATIONS

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

BIRTHDATE can be completed without difficulty. Simply use FormsPal PDF editor to complete the job fast. FormsPal team is continuously endeavoring to develop the tool and ensure it is even easier for people with its many features. Enjoy an ever-improving experience today! By taking several basic steps, you may begin your PDF editing:

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How one can complete VII part 1

2. Once the previous part is complete, you should add the necessary specifics in WHAT COULD HAVE PREVENTED THE, and Form is continued on reverse page so you're able to move forward further.

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

3. The following portion will be about DDFF PAGE, INDIVIDUALS NAME Last First MI, TYPE OF MEDICAL INTERVENTION, LOCATION OF MEDICAL INTERVENTION, NOTIFICATIONS, DATE OF INCIDENT, Serious incidents as described in, All other incidents as described, NOTIFIED BY WHOM Last First MI, DATETIME OF NOTIFICATION, Yes, SUPPORT COORDINATOR NOTIFIED, Yes, CHILDADULT PROTECTIVE SERVICES, and Yes - fill in all these blanks.

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

People often make some errors when filling in Yes in this area. Don't forget to go over whatever you type in here.

4. The fourth section comes next with these blanks to type in your particulars in: PRINT SUPERVISORS NAME, SIGNATURE OF SUPERVISOR, and DATE.

Step no. 4 for filling in VII

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