DIDS REPORTABLE INCIDENT
Exit this survey 
*

1. Name of Service Recipient
(Last, First, MI)

*

2. SSN
(Enter the hyphen in the number)

3. Date/Time of Incident

 MM DD YYYY HH MMAM/PM 
Date/Time
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4. Region

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5. Provider Responsible

*

6. Provider Code

7. Provider Reporting (if different)

*

8. Description of Incident (what, where, when, who):

9. This incident was

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10. Address/Site of Incident

11. Where incident occurred (Check one)

12. This incident required (Check all that apply. Include diagnosis, treatment, and follow-up information for *starred items.)

13. Description of Injury - When applicable, describe type, size, location/body part, color or injury; type and location of treatment, etc.

14. Injury (check one)

15. Type of Incident (Check all applicable types. All *starred types must be immediately reported to the DIDS Investigation Hotline.)

DIDS investigator must be notified within 4 hours for alleged abuse, neglect, mistreatment, exploitation, serious injury of unknown cause, for any questionable or suspicious death, or for any injury that raises the suspicion of abuse, neglect, or exploitation based on size, location, etc.

16. Notified

17. Family/Guardian Notified (Date/Time)

 MM DD YYYY HH MMAM/PM 
Date/Time
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/
 
:
 

18. ISC Provider Notified (Date/Time)

 MM DD YYYY HH MMAM/PM 
Date/Time
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/
 
:
 

19. APS/DCS Notified (Date/Time)

 MM DD YYYY HH MMAM/PM 
Date/Time
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/
 
:
 

20. Regional Pager Notified (Date/Time)

 MM DD YYYY HH MMAM/PM 
Date/Time
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21. Investigator Notified (Date/Time DIDS)

 MM DD YYYY HH MMAM/PM 
Date/Time
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:
 

22. Person Reporting Incident (Print Name)

23. Date/Time Reported

 MM DD YYYY HH MMAM/PM 
Date/Time
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/
 
:
 

24. Signature