"Unusual Incident Monthly Report Log Form for Independent Providers"

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Unusual Incident Monthly Report Log for Independent Providers
All information needed to complete this form should come from the corresponding Unusual Incident Report that has already been completed.
Independent
Provider
Provider Name:
Address:
Email Address:
Month:
Year:
Providing services for the following consumers:
Name
Date
Injury
Location
Description of Incident
Immediate Action Taken to
Causes &
Prevention Plan
UI
and Time
(Explain Risk of Harm)
Ensure Health & Welfare
Contributing Factors
am
pm
am
pm
am
pm
am
pm
am
pm
Reviewed By:
Title: Independent Provider
Date:
Trends and Patterns Identified?
YES
No
Trends and Patterns Addressed?
YES
No
(If YES, please complete section below.)
Action taken to address identified Patterns and Trends:
O.A.C. 5123:2-17-02(M)(6) Each independent provider shall review all unusual incidents as necessary, but no less than monthly to ensure appropriate preventative measures have been
implemented and trends and patterns identified and addressed as appropriate. O.A.C. 5123:2-17(M)(8) Each independent provider shall maintain a log of all unusual incidents. The log shall include,
but is not limited to, the name of the individual, a brief description of the unusual incident, any injuries, time, date, location, and preventative measures.
This form is to be completed, reviewed, and stored by the Independent Provider.
12/2013, revised 01/24/2014
Submitted by, Printed Name:
Date:
By checking this box, I agree that my printed name I have entered above, will be the legal electronic representation of my signature.
If you are unable to utilize the "submit by email" button, this form can also be printed out and faxed to 440.326.0247, or scanned and attached to an email sent to IPemail@murrayridgecenter.org.
Submit to County by Email
Unusual Incident Monthly Report Log for Independent Providers
All information needed to complete this form should come from the corresponding Unusual Incident Report that has already been completed.
Independent
Provider
Provider Name:
Address:
Email Address:
Month:
Year:
Providing services for the following consumers:
Name
Date
Injury
Location
Description of Incident
Immediate Action Taken to
Causes &
Prevention Plan
UI
and Time
(Explain Risk of Harm)
Ensure Health & Welfare
Contributing Factors
am
pm
am
pm
am
pm
am
pm
am
pm
Reviewed By:
Title: Independent Provider
Date:
Trends and Patterns Identified?
YES
No
Trends and Patterns Addressed?
YES
No
(If YES, please complete section below.)
Action taken to address identified Patterns and Trends:
O.A.C. 5123:2-17-02(M)(6) Each independent provider shall review all unusual incidents as necessary, but no less than monthly to ensure appropriate preventative measures have been
implemented and trends and patterns identified and addressed as appropriate. O.A.C. 5123:2-17(M)(8) Each independent provider shall maintain a log of all unusual incidents. The log shall include,
but is not limited to, the name of the individual, a brief description of the unusual incident, any injuries, time, date, location, and preventative measures.
This form is to be completed, reviewed, and stored by the Independent Provider.
12/2013, revised 01/24/2014
Submitted by, Printed Name:
Date:
By checking this box, I agree that my printed name I have entered above, will be the legal electronic representation of my signature.
If you are unable to utilize the "submit by email" button, this form can also be printed out and faxed to 440.326.0247, or scanned and attached to an email sent to IPemail@murrayridgecenter.org.
Submit to County by Email