Form Rcoc 586 V – Fill Out and Use This PDF

The RCOC 586-V form, also known as the Special Incident Report, is a critical document utilized by the Regional Center of Orange County for reporting various incidents involving its consumers, including abuse, neglect, medication errors, emergency hospitalizations, and more, as required by Title 17, §54327. It serves as a comprehensive tool for documenting and communicating important details about incidents to ensure the well-being and safety of consumers in their care. If you or someone you know needs to report an incident, don't hesitate; click the button below to learn how to properly fill out and submit the RCOC 586-V form.

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Form Rcoc 586 V PDF Details

In the world of healthcare and support for individuals with disabilities, detailed reporting and accountability are paramount. The Regional Center of Orange County outlines specific protocols for recording and addressing incidents involving consumers under its care through the Special Incident Report form designated RCOC 586 V. This document is comprehensive, requiring detailed information about the consumer, including name, sex, date of birth, and unique identification number. It promptly asks for specifics about the incident, such as the time, location, and nature of the event, ensuring that each case is treated with the urgency and specificity it deserves. Critical incidents, from medication errors to abuse or neglect, and from serious injuries to unexpected hospitalizations, must be reported. Moreover, it includes a section for additional observations and events that may not fit into predefined categories but are essential for ensuring the consumer's health, safety, and well-being. The form also seeks information on immediate actions taken, medical treatments provided or required, and plans to prevent future occurrences, making it not just a report but a tool for ongoing improvement and safety. Compliance with Title 17 requirements underscores the legal and ethical responsibility to provide a safe environment for all consumers, marking the form as an essential piece of documentation in the continuum of care and protection for individuals with disabilities.

Question	Answer
Form Name	Form Rcoc 586 V
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	586-V, UCI, RCOC, APS

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REGIONAL CENTER OF ORANGE COUNTY

Special Incident Report Other Observations and Events

FAX TO 714-796-0600

Consumer’s Name: _________________________________ Sex: M F Date of Report: _________________

Date of Birth: __________________ UCI Number: __________________________ Date/Time of Incident: _____________________________

Check Applicable: Verbal

Non-Verbal Ambulatory Non-Ambulatory

Location of Incident: ______________________________

REQUIRED BY TITLE 17, §54327

Death of a consumer (regardless of cause or location)

Consumer was the victim of a crime (regardless of location)

Reasonably suspected neglect:

A serious injury/accident, including:

฀ Failure to provide medical care

฀ Dislocation

฀ Failure to prevent malnutrition/dehydration

฀ Fracture

฀ Failure to protect from health/safety hazard

฀ Laceration requiring sutures/staples/Dermabond

฀ Failure to assist with personal hygiene

฀ Burns, bites, puncture wounds or internal bleeding requiring

฀ Failure to provide food/clothing/shelter

treatment beyond first aid

฀ Failure to provide care

฀ Medication reaction requiring treatment beyond first aid

Reasonably suspected abuse/exploitation

฀ Any medication error (see below)

฀ Physical

฀ Psychological

Unplanned or unscheduled hospitalization due to:

฀ Sexual

฀ Physical restraint

฀ Respiratory illness

฀ Diabetes-related activity

฀ Fiduciary

฀ Chemical restraint

฀ Seizure-related activity

฀ Wound/Skin care

The consumer is missing and the vendor has filed a Missing

฀ Internal infection

฀ Involuntary psychiatric

Persons Report with a law enforcement agency

admission

FOR MEDICATION ERRORS

Additional incident types required for FHA per Title 17, §56093

Name of Medication

Dosage Schedule of Medication

Any occurrence/allegation of consumer abuse

Event which may result in criminal charges or legal action

Event which may result in denial of consumer’s right(s)

Event which appears to have a significant negative affect on

consumer’s health, safety, or well-being

Poisonings

Catastrophes

Emergency treatment

Fires or explosions

OTHER EVENTS/OBSERVATIONS

Alleged violation of consumer’s right(s)

Diagnosis of communicable disease/parasite

Voluntary psychiatric

hospitalization

Use of restrictive behavior intervention

Medical emergency

Event which may result in criminal changes/legal action

Unauthorized absence

Arrest

Injury:

Health and safety issue

฀ From a seizure

฀ From a behavior episode

Other sexual incident:

฀ From a peer

฀ Sexual harassment

฀ Inappropriate contact

Suicide episode:

Behavior episode:

฀ Threat

฀ Attempt

฀ Aggressive act to self

฀ Aggressive act to staff

Property Damage

฀ Aggressive act to peer

฀ Aggressive act to family or

Other

฀ Aggressive act to

visitor

community member

฀ Other

OTHER AGENCIES/INDIVIDUALS INVOLVED

Contact Name

Telephone

Report Number

Community Care Licensing (DSS)

Licensing and Certification (DHS)

Parent/Guardian/Conservator

Physician/Hospital

Police/Sheriff

County Coroner

Other Family Member/Vendor

Investigating Agency Involved:

Select Agency Name

Type

APS

CPS

LTCO

Investigation

Declined

For Information Only

COMPLETE FRONT/BACK -- CONFIDENTIAL CLIENT INFORMATION - W&I CODE, SECTION 4514 -- SPECIAL INCIDENT REPORT

RCOC #586-V - Rev 5/08

Page 1 of 2

DESCRIPTION OF INCIDENT (Title 17 requires a description of the alleged perpetrator, if applicable):

(Attach a separate page for additional information if necessary)

IMMEDIATE ACTION TAKEN BY SERVICE PROVIDER/VENDOR/OTHER:

(Attach a separate page for additional information if necessary)

MEDICAL TREATMENT NECESSARY: Yes No If Yes, Nature of Treatment:

Administered At: ___________________________________

Administered By:_____________________________________

Follow-Up Treatment, If Any:

PLAN TO PREVENT FURTHER OCCURRENCES:

(Attach a separate page for additional information if necessary)

COMMENTS (INCLUDE THE NAME/ADDRESS OF ANY WITNESS TO THE INCIDENT):

(Attach a separate page for additional information if necessary)

	REPORT SUBMITTED BY

Name (print):		Title:
Vendor Name:		Vendor Number:
DHS-L&C Lic. #:		DSS-CCL Lic. #:
Telephone Number:		Signature/Date:
COMPLETE FRONT/BACK -- CONFIDENTIAL CLIENT INFORMATION - W&I CODE, SECTION 4514 -- SPECIAL INCIDENT REPORT
RCOC #586-V - Rev 5/08	Page 2 of 2

Form Rcoc 586 V – Fill Out and Use This PDF

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