INCIDENT REPORT ASSIGNMENT
TYPES OF INCIDENTS
An incident is an event or occurrence that could potentially impact the health and well-being of
an individual, his/her relatives, the State of Arizona, the service provider or the community. This
could include situations that may be considered news-worthy and/or incur liability to the State
of Arizona or the provider agency. An incident is anything that could negatively impact the
person, the provider or the Division. Incidents must be reported.
Some incidents are considered “serious” incidents and have a higher reporting priority. If you
are ever not sure if something would be considered a Serious Incident, just notify your
supervisor right away and they will help you determine the reporting procedure that should be
followed.
Types of Incidents - Examples Incidents can include, but are not limited to:
• Death of an individual.
• Potentially dangerous situations due to neglect of an individual.
• Allegations of suspected sexual, physical, programmatic, or verbal/emotional abuse.
• A missing individual.
• Accidental injuries that may or may not result in medical intervention.
• Violation of an individual’s rights.
• Fraud (for example: falsifying timesheets).
• Complaints about a group home or someone who live in a group home.
• Allegations of inappropriate sexual behavior.
• Circumstances that pose a threat to the health, safety or welfare of individuals, such as
loss of air conditioning, loss of water or loss of electricity.
• Use of behavior management techniques that are not part of a behavior building plan.
• Theft or loss of an individual’s money or property.
• Physical management techniques employed in an emergency to manage a sudden,
intense, or out-of-control.
• Problems with medications.
• Community disturbances in which the individual or the public may have been placed at
risk.
• Serious work-related illness or injury.
• Threats to Division or provider employees or property and non-consumer/non-
employee accidents that occur on state or provider property.
• Unplanned hospitalization or emergency room visit in response to an illness, injury, or
medication error.
• Unusual weather conditions or other disasters resulting in an emergency change of
operations.
• Provider drug use.
Serious incidents
Serious incidents require immediate notification to the Division of Developmental Disabilities
(DDD). The Division interprets “immediately” as the first allowable opportunity that does not
place the consumer or staff at undue risk, as applicable to the situation. Notification must occur
within 24 hours of the incident. If someone in your agency is not available, you are required to
report this incident directly to the Division/support coordinator; check your agency’s policy for
reporting. The DCW must also report all suspected incidents of abuse and neglect to the
appropriate protective services and law enforcement agency.
Principles of Caregiving – Developmental Disabilities
Incident Reporting – If in doubt, fill it out!
Serious incidents could include, but are not limited to:
• All deaths.
• All suspected allegations of abuse and neglect.
• Any situation that poses a serious and immediate threat to the physical or emotional
well-being of an individual or staff member.
• Severe personal injury – a physical injury that creates a reasonable risk of death, causes
serious or permanent disfigurement or causes serious impairment of a consumer’s
health.
• A situation in which a person, who cannot be unsupervised at home or in the
community, runs away or is missing.
• Property damage estimated in excess of $10,000.
• A situation that involves the theft or loss of an individual’s money or property of more
than $1000.
• A situation that involves reporting to law enforcement officials because a Division-
enrolled individual is missing and presumed to be in imminent danger.
• A situation that involves reporting to law enforcement officials due to possession and/or
illegal substance use by individuals or staff/providers.
• A situation that results in a 911 call due to a suicide attempt by an individual.
• A situation that involves an incident or complaint from the community that will be or is
reported on the front pages of the newspaper or on television/radio.
• Your employer may also want you to report damage to any property or other situations
that are “out of the ordinary.” Your agency will determine whether to classify
theseincidents as serious or not.
INCIDENT REPORTING
1. Basics: The purpose of incident reporting
▪ A communication tools.
o A way to protect the Direct Care Worker.
o An incident report protects the direct care worker, the agency they work for,
and the province of Ontario by ensuring that all responses to an incident are
documented.
▪ A way to promote health and safety.
o an incident report ensures that issues are addressed that could negatively affect the
person.
▪ A method for gathering trending data.
o Incident reporting helps the family and team to see patterns and provides a record
of incidents and occurrences. This may benefit the family and team in addressing
triggers or patterns of problems that have occurred.
▪ A way to reduce the likelihood of recurrence.
o It allows the family and team to address problem areas. For example, if a person is
hitting their shins as they get out of bed, causing injury and pain, an incident report will
let everyone know that there is a problem with the bed or bedroom set up so that it
can be changed.
▪ A way to provide communication between responsible parties, the Division of
Developmental Disabilities, the provider agency, and the Direct Care Worker.
▪ A tool to report on issues of concern that need follow-up.
▪ Without an incident report, the people who are in a position to make a difference may
not know all the information they need to take action. The incident report allows the
provider agency, that province of Ontario, and the responsible person and family
(when appropriate) to take the steps needed
▪ For serious incidents
▪ Complete a written report of the serious incident as soon as possible, but before the
end of your work day.
▪ The provider agency must provide a verbal and written report to the ministry.
▪ Within 24 hours of a serious incident the following actions must be taken: Notification
to the responsible person (guardian, family member, etc.) must be made within
24hours.
2. When completing an incident report All incident reports must be:
▪ Completed in blue or black ink. Your agency may require you to use a specific color.
Corrected accurately.
▪ If you make an error, draw a single line through the error and your initials and the date
the change was made.
▪ o Never scribble out an error.
o Never use correction fluid or tape on an incident report form.
▪ o Never erase anything on an incident report.
▪ Written clearly, objectively and in the order of occurrence, without reference to the
writer’s opinion. Keep in mind that these reports are available to family/guardians and
are considered legal documents. “Objective” means you state facts, not opinions.
▪ IMPORTANT NOTE: Stress that when writing objectively, the worker should state only
the facts that they know. They should not include opinion. For example: A good
example “Music was playing on the radio in the living room. Sally came out of her room
and made the statement “the music is bothering me. Please turn it off.”
▪ Bad example: Sally came storming out of her room because she didn’t like the song
that was playing on the radio and demanded that I turn it off. She was really mad.
3. All incident reports:
▪ include demographic information like:
o Full name
o Address
o Date of birth
o Identification number
• Include the names and titles of all Direct Care Workers who witnessed the incident or
were involved in it.
• Include a description of the incident including all known facts, location, and the date and
time the incident occurred.
• Include causes of injury (if applicable).
• State whether or not the responsible person was notified and, if not, the reason.
• Include whether or not law enforcement, Adult/Child Protective Services, or Tribal
Social Services have been contacted.
• Include signatures and names of the person completing the report and his/her
supervisor and any additional comments.
• Must be completed for each individual involved in the incident and not breach the
confidentiality of other individuals.
• Must be maintained by the provider agency and the Division of Developmental
Disabilities Support Coordinator.
• If more than one individual who receives services through the Division of Developmental
Disabilities is involved in the incident, write a separate report for each person. Use only
the individual’s name for which the report is being written. Refer to other persons
generically, e.g. housemate, roommate, peer, friend, etc.
INCIDENT REPORT ASSIGNMENT:
Instructions:
1. Using a template incident form provided, complete a practice report based
on the scenario you have been assigned.
2. You may not have all the information you need to complete the report.
Dates and times are not provided. You should use the current date and
time. The incident you have been assigned may ask you to create other
information.
3. Remember your incident reporting basics:
1. Maintain confidentiality.
2. State only facts.
3. Cite your sources.
4. Use quotes when possible.
5. Be clear – use bullet points for clarity.
Scenario:
Sally experienced a seizure. During the seizure she hit her head on the ground
causing swelling and bleeding. You call 911 and she is transported to the hospital
where she is kept overnight for monitoring.
