Incident Reporting Form at a glance
What it is: This is the Bureau of Human Services Licensing Incident Reporting Form.
A filled-in Incident Reporting Form example: a Final report of a fall
How to fill out Incident Reporting Form, box by box
Type of Report and Regulatory Chapter
Mark the Type of Report: Initial, Final or Initial/Final.
Mark the Regulatory Chapter.
Facility Information
Under Facility Information, enter the Name of Legal Entity, the Name of licensed setting as it appears on license and the Facility Address.
Enter the License Number and the Phone Number.
Incident Information
Enter the Date Of Incident and the Time of Incident (AM/PM).
Enter the Regulation # and type of incident, the Date Incident reported to Department and the Time Incident reported to Department (AM/PM).
Resident Information
Complete the Resident Information for any incident relating to a specific resident(s): Name (Last, First) and Date of Birth.
Persons Involved
Under Persons Involved enter the Name (Last, First) and Job Title. Example: Staff Person, Responding Officer, etc.
Description of Incident
Description of Incident (Attach Additional Pages as Necessary): Please provide as much detail as possible about the incident, including what happened, where it happened, when it happened, the licensed setting's response, etc.
Follow-Up Action Taken
Under Follow-Up Action Taken, enter what action, if any, was initiated or is planned in response to the incident. Include any contacts made.
Contact Information
Under Contact Information enter the Name of person completing report, the Title, the Contact Person Name and the Telephone Number.
Sources
[1] Bureau of Human Services Licensing Incident Reporting Form, Pennsylvania Department of Human Services (the Official source link on this page).