Form MO650-9475 "Community Event Report Form - Emt - Behavioral Health" - Missouri

What Is Form MO650-9475?

This is a legal form that was released by the Missouri Department of Mental Health - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2015;
  • The latest edition provided by the Missouri Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO650-9475 by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download Form MO650-9475 "Community Event Report Form - Emt - Behavioral Health" - Missouri

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Print Form
Event #
DMH Use Only
**Please note all signatures are required to be original signatures. Please complete the form electronically, print, sign and submit to the department.**
Department of Mental Health
EMT - Community Event Report Form - Behavioral Health
Division
Alcohol and Drug Abuse (ADA)
Comprehensive Psychiatric Services (CPS)
1. EVENT DATE & TIME:
2. DISCOVERY DATE & TIME:
AM
AM
PM
PM
3. EVENT LOCATION OR WHERE DISCOVERED:
4. NAME OF PROVIDER AGENCY/ORGANIZATION INVOLVED IN EVENT:
0
(Name of agency or location)
5. EVENT CATEGORY: (Check One)
INCIDENT (Includes Death)
MEDICATION ERROR
6. PROGRAM CATEGORY PERTINENT TO EVENT:
ADA Only:
Adult or
Adolescent
Choose a service type:
CPS Only:
Adult or
Youth
Choose a service type:
7. REPORTABLE EVENT:
All events identified below shall be recorded on this form and faxed within one (1) business day to the appropriate division, Division
of Alcohol and Drug Abuse District Administrator or the Division of Comprehensive Psychiatric Services Supported Community Living Office.
Death (All deaths, including those of consumers within 15 days post-discharge from residential programs.) If checked complete suspected manner (14)
Death (All deaths, including those of consumers within 15 days post-discharge from residential programs.) If checked complete suspected manner (14)
Injury resulting in medical inpatient hospitalization, where the injury is secondary to community agency activities. If checked complete all of 8 - 15.
Self Injurious Behavior or Suicide Attempt (if resulting in death or injury as defined above)
Self Injurious Behavior or Suicide Attempt (if resulting in death or injury as defined above)
Sexual Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Sexual Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Physical Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Elopement/ Unauthorized Absence - For CPS, when from a congregate living or semi-independent environment of a consumer who has a
guardian or is NGRI or who is suspected of posing an imminent risk of harm to self or others. For ADA, this applies to adolescents and
AM
involuntary commitments only. For consumers in dual ADA/CPS programs,
PM
both ADA and CPS criteria apply but only 1 report needed.
Return Date:
Time:
MEDICATION ERROR(Occurring in residential programs or programs in which medication is administered or self administration is observed by the agency.)
Severity: (SELECT ONE)
Medication Error Category:
Failure to Administer
Wrong Form
Moderate: Treatment and/or interventions in addition to monitoring or observation
Wrong Medication
Wrong Person
Serious: Life threatening and/or permanent adverse consequences
Wrong Dose
Reason:
Wrong Route
Wrong Time
Alleged or Suspected Abuse, Neglect, or Misuse of Funds/Property
No Physician Order
Select Type: (all that apply)
Verbal Abuse
Physical Abuse
Sexual Abuse
Neglect
Misuse of Funds/Property
If Physical Abuse, Verbal Abuse, Sexual Abuse, Misuse of Consumer Funds/Property or Neglect is alleged by a consumer or suspected by staff, report this
immediately by verbal or written report and follow all other procedures described in 9 CSR 10-5.200.
8. PERSONS INVOLVED :
Relationship
Role
DMH State #
Date of last Services
Please PRINT (attach pages if necessary)
(for consumers)
(for consumers)
Relationship Types: Consumer, Parent, Guardian, Staff, Visitor, Volunteer, Other (PLEASE SPECIFY)
Role Types: Complainant, Perpetrator, Victim, Witness, Other (PLEASE SPECIFY)
MO 650-9475 (4/15)
Page 1 of 3
Print Form
Event #
DMH Use Only
**Please note all signatures are required to be original signatures. Please complete the form electronically, print, sign and submit to the department.**
Department of Mental Health
EMT - Community Event Report Form - Behavioral Health
Division
Alcohol and Drug Abuse (ADA)
Comprehensive Psychiatric Services (CPS)
1. EVENT DATE & TIME:
2. DISCOVERY DATE & TIME:
AM
AM
PM
PM
3. EVENT LOCATION OR WHERE DISCOVERED:
4. NAME OF PROVIDER AGENCY/ORGANIZATION INVOLVED IN EVENT:
0
(Name of agency or location)
5. EVENT CATEGORY: (Check One)
INCIDENT (Includes Death)
MEDICATION ERROR
6. PROGRAM CATEGORY PERTINENT TO EVENT:
ADA Only:
Adult or
Adolescent
Choose a service type:
CPS Only:
Adult or
Youth
Choose a service type:
7. REPORTABLE EVENT:
All events identified below shall be recorded on this form and faxed within one (1) business day to the appropriate division, Division
of Alcohol and Drug Abuse District Administrator or the Division of Comprehensive Psychiatric Services Supported Community Living Office.
Death (All deaths, including those of consumers within 15 days post-discharge from residential programs.) If checked complete suspected manner (14)
Death (All deaths, including those of consumers within 15 days post-discharge from residential programs.) If checked complete suspected manner (14)
Injury resulting in medical inpatient hospitalization, where the injury is secondary to community agency activities. If checked complete all of 8 - 15.
Self Injurious Behavior or Suicide Attempt (if resulting in death or injury as defined above)
Self Injurious Behavior or Suicide Attempt (if resulting in death or injury as defined above)
Sexual Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Sexual Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Physical Assault (in which a consumer is either perpetrator or victim) occurring on community agency property or during provision of services
Elopement/ Unauthorized Absence - For CPS, when from a congregate living or semi-independent environment of a consumer who has a
guardian or is NGRI or who is suspected of posing an imminent risk of harm to self or others. For ADA, this applies to adolescents and
AM
involuntary commitments only. For consumers in dual ADA/CPS programs,
PM
both ADA and CPS criteria apply but only 1 report needed.
Return Date:
Time:
MEDICATION ERROR(Occurring in residential programs or programs in which medication is administered or self administration is observed by the agency.)
Severity: (SELECT ONE)
Medication Error Category:
Failure to Administer
Wrong Form
Moderate: Treatment and/or interventions in addition to monitoring or observation
Wrong Medication
Wrong Person
Serious: Life threatening and/or permanent adverse consequences
Wrong Dose
Reason:
Wrong Route
Wrong Time
Alleged or Suspected Abuse, Neglect, or Misuse of Funds/Property
No Physician Order
Select Type: (all that apply)
Verbal Abuse
Physical Abuse
Sexual Abuse
Neglect
Misuse of Funds/Property
If Physical Abuse, Verbal Abuse, Sexual Abuse, Misuse of Consumer Funds/Property or Neglect is alleged by a consumer or suspected by staff, report this
immediately by verbal or written report and follow all other procedures described in 9 CSR 10-5.200.
8. PERSONS INVOLVED :
Relationship
Role
DMH State #
Date of last Services
Please PRINT (attach pages if necessary)
(for consumers)
(for consumers)
Relationship Types: Consumer, Parent, Guardian, Staff, Visitor, Volunteer, Other (PLEASE SPECIFY)
Role Types: Complainant, Perpetrator, Victim, Witness, Other (PLEASE SPECIFY)
MO 650-9475 (4/15)
Page 1 of 3
Event or
Discovery Date and Time
AM
PM
Date
Time
9. INJURY TYPE (SELECT ONE)
Accident
Consumer Inflicted
Other Inflicted
Self Inflicted
Staff Inflicted
Unknown
10. INJURY DESCRIPTION (CHECK ALL THAT APPLY)
11. INJURED BODY PARTS (CHECK ALL THAT APPLY)
Hip - Right
Shoulder - Right
Abrasion
Calf - Right
Puncture
Lower Abdomen
Head
Shoulder - Left
Calf - Left
Bite
Scratches
Face
Waist
Upper Arm - Right
Shin - Right
Burn
Strain/Sprain
Eye - Right
Upper Arm - Left
Hip - Left
Shin - Left
Complaint of Pain
Eye - Left
Swelling
Elbow - Right
Genitials
Ear - Right
Ankle - Right
Contusion/Bruise
Elbow - Left
Buttock - Right
Other (Specify)
Ear - Left
Ankle - Left
Forearm - Right
Buttock - Left
Dislocation
Nose
Forearm - Left
Foot - Right
Thigh - Right
Fracture/Break
Mouth
Wrist - Right
Thigh - Left
Foot - Left
Teeth
Frostbite
Other:
Wrist - Left
Knee - Right
Neck
Heat related illness
Hand - Right
Knee - Left
Upper Back
Other:
Laceration/Cut
Hand - Left
Lower Back
Chest
Thumb - Right
Index - Right
Middle - Right
Ring - Right
Little - Right
Thumb - Left
Index - Left
Middle - Left
Ring - Left
Little - Left
Big - Right
2nd - Right
3rd - Right
4th - Right
Little - Right
4th - Left
Big - Left
2nd - Left
3rd - Left
Little - Left
12. NOTIFIED:
Name of Person Contacted
Date
Time
AM
Family or Guardian
PM
AM
Physician
PM
AM
Law Enforcement
PM
AM
Dept. of Mental Health
PM
AM
DSS Children's Division
PM
AM
DHSS
PM
AM
911
PM
AM
Other (Coroner or M.E.)
PM
AM
Other
PM
AM
Other
PM
AM
Other
PM
13. EVENT DESCRIPTION: Describe what happened and interventions used by staff.
Attach additional pages if necessary.
Page 2 of 3
MO 650-9475 (4/15)
Event or
Discovery Date and Time
AM
PM
Date
Time
14. IMMEDIATE ACTION TAKEN BY AGENCY AND ACTION STEPS TO PREVENT REOCCURANCE: (To be completed by agency management if action
was required.)
If a death occurred: Suspected Manner of Death
ACCIDENT
HOMICIDE
NATURAL
SUICIDE
UNDETERMINED
If Yes, list Coroner/ Medical Examiner:
Is an Autopsy being performed?
YES
NO
UNKNOWN
15. SIGNATURE - REPORTER:
Agency Name:
Reporter's Signature:
Print Reporter's Name:
Date / Time Reporter
Phone Number:
Signed:
***Please note all signatures are required to be original signatures. Please complete the form electronically, print, sign and submit to the
department.***
To be Completed by Department of Mental Health Staff
16. ACTION/ COMMENTS
Incident Type:
Inappropriate language by staff toward consumer
Sexual conduct-consumer/non-consensual
Medical emergency-Consumer
Sexual conduct-staff & consumer
Consumer Self Harm
Misuse of consumer funds/property
Suicide attempt
Violation of Consumer Rights
Physical altercation-between consumers
Theft by consumer
Consumer struck object resulting
Physical altercation-consumer & non-staff
Vehicular accident
Physical altercation-Staff & Consumer
in injury
Fall
Possession of Weapon
Other
Fire
Property loss/destruction
If other selected, please explain:
Was the event a Critical Incident?
If yes to either question, must be entered
YES
NO
into EMT within 24 hours.
Suspicion or Allegation of Abuse, Neglect or Misuse of Consumer Funds/ Property?
YES
NO
Decision:
Result:
Inquiry
Local Review
Death Review
No Action Taken
Accepted
Declined
CO Invesitigation Required
Notes:
Check any of the following contacts that are required:
DMH Facility Head
Parent/ Guardian
Local Law Enforcement
DHSS
DSS
Signature of DMH Staff:
Date:
Additional Notes:
MO 650-9475 (4/15)
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