"Serious Injury Report Form" - Minnesota

Serious Injury Report Form is a legal document that was released by the Minnesota Office of the Ombudsman for Mental Health and Developmental Disabilities - a government authority operating within Minnesota.

Form Details:

  • Released on September 1, 2018;
  • The latest edition currently provided by the Minnesota Office of the Ombudsman for Mental Health and Developmental Disabilities;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Office of the Ombudsman for Mental Health and Developmental Disabilities.

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121 7th Place East, Suite 420, St. Paul, MN 55101
Voice – 651-757-1800 Toll Free – 800-657-3506
Please attach supporting documentation
Complete this form and fax to
651-797-1950 or 651-296-1021
Serious Injury Report
Date of Report: ________________
(If all information is not available within 24 hours, submit report with information you have)
CLIENT INFORMATION
Last Name:
First Name:
MI:
Gender:
Female
____ Male
Other
Date of Birth:
Ethnicity:
African American
Choose Not to Respond
African
Hispanic or Latino
American Indian or Native Alaskan
Other
Asian
Pacific Islander or Native Hawaiian
Caucasian or White
County of Residence:
County of Financial Responsibility:
Address type:
Address at time of Case (Temporary)
Permanent Address (Home)
Address:
Apt/Suite #:
City:
County:
State:
Zip:
Home Number: (
)
Ext:
May we leave a message?
Yes
No
Cell/Mobile Number: (
)
Name of Residence (if any):
If address above is temporary please provide the permanent address below
Type of License:
License Number:
Address:
Apt/Suite #:
City:
County:
State:
Zip:
Phone Number: (
)
Ext:
Alternate Number: (
)
Ext:
Fax:
(
)
REPORTER INFORMATION
Do you wish to have your identity private?
Yes
No
Do you have concerns about retaliation?
Yes
No
Last Name:
First Name:
Title:
Agency/Program Name:
Email address:
Address:
Apt/Suite#:
City:
County:
State:
Zip:
Work Number:
(
)
Ext:
May we leave a message?
Yes
No
Cell/Mobile Number: (
)
Fax Number: (
)
Who else did you report this to? (Check all that apply)
Administration
Guardian or Legal Representative
Adult or Child Protection or MAARC
Hospital Review Board
Attorney Legal
Law Enforcement
County Agency
Licensing Agency
Facility or Program or Agency Staff
Medical Resources Health Care Provider
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121 7th Place East, Suite 420, St. Paul, MN 55101
Voice – 651-757-1800 Toll Free – 800-657-3506
Please attach supporting documentation
Complete this form and fax to
651-797-1950 or 651-296-1021
Serious Injury Report
Date of Report: ________________
(If all information is not available within 24 hours, submit report with information you have)
CLIENT INFORMATION
Last Name:
First Name:
MI:
Gender:
Female
____ Male
Other
Date of Birth:
Ethnicity:
African American
Choose Not to Respond
African
Hispanic or Latino
American Indian or Native Alaskan
Other
Asian
Pacific Islander or Native Hawaiian
Caucasian or White
County of Residence:
County of Financial Responsibility:
Address type:
Address at time of Case (Temporary)
Permanent Address (Home)
Address:
Apt/Suite #:
City:
County:
State:
Zip:
Home Number: (
)
Ext:
May we leave a message?
Yes
No
Cell/Mobile Number: (
)
Name of Residence (if any):
If address above is temporary please provide the permanent address below
Type of License:
License Number:
Address:
Apt/Suite #:
City:
County:
State:
Zip:
Phone Number: (
)
Ext:
Alternate Number: (
)
Ext:
Fax:
(
)
REPORTER INFORMATION
Do you wish to have your identity private?
Yes
No
Do you have concerns about retaliation?
Yes
No
Last Name:
First Name:
Title:
Agency/Program Name:
Email address:
Address:
Apt/Suite#:
City:
County:
State:
Zip:
Work Number:
(
)
Ext:
May we leave a message?
Yes
No
Cell/Mobile Number: (
)
Fax Number: (
)
Who else did you report this to? (Check all that apply)
Administration
Guardian or Legal Representative
Adult or Child Protection or MAARC
Hospital Review Board
Attorney Legal
Law Enforcement
County Agency
Licensing Agency
Facility or Program or Agency Staff
Medical Resources Health Care Provider
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Office of Health Facility Complaints (OHFC)
Private Agency
Advocacy/Ombudsman Agency
State Agency
Other – describe
Treatment Team
ADDITIONAL CLIENT INFORMATION
Client Category (check all that apply):
Brain Injury (TBI)
Emotional Disturbance
Other
Chemical Dependency
Mental Illness
Sex Offender
Developmental Disabilities
Mentally Ill and Dangerous
Legal Representatives (check all that apply):
Health Care Agent
Private Conservator
Health Care Directive
Private Guardian
None
Public Guardian
Nonparent/Relative
Representative Payee
Parent
Substitute Decision Maker (Commitment Statute
Power of Attorney for Health Care Agent
253B.092)
Power of Attorney
Legal Status at Time of Injury (check all that apply):
Committed - Chemical Dependency (CD)
Juvenile Court Placement
Committed - Developmental Disability (DD)
None
Committed - Mentally Ill (MI)
Probation
Committed - Mentally Ill and Dangerous (MI&D)
Provisional Discharge
Committed - Sexual Psychopathic Personality (SPP)
Rule 20
Committed - Sexually Dangerous Person (SDP)
Stay of Commitment
Emergency Hold Court Order
Unknown
Informal Juvenile Placement by Parents
Voluntary Admission
SERIOUS INJURY INFORMATION
Date of Injury (if known):
Time of Injury: ______
a.m. or p.m.
Did this injury occur where the client lives?
Yes
No
If not, Name of Agency, Facility or Program (if any) where Serious Injury Occurred:
Address:
City:
State:
Zip:
Telephone Number: (
)
Fax: (
)
County:
Type of License:
License Number:
Location Where Serious Injury Occurred (check one):
Adult Day Care Services
Hospitals and Critical Access Hospital
Assisted Living Program – Class E
Job or Work (other than in program)
Board and Lodge Housing with Services
Minnesota Sex Offender Program – Moose Lake
Board and Lodge
Minnesota Sex Offender Program – Saint Peter
Boarding Care Home
Nursing Home
Substance Use Disorder Treatment
Other - Describe
Children’s Residential Facilities
Outpatient Surgical Center
Community
Own home or Apartment
Community Mental Health Center
Psychiatric Hospital
Crisis Home
Relatives/Friends Home
Crisis Respite Services
Residential Facilities for Adults with MI
Day Training and Habilitation Services
Residential Programs & Services for Physically Disabled
Detox Services
Residential Services, ICF/DD certified
Family Adult Day Services
Residential Services, non-ICF/DD certified
Family Child Care
School
Forensic Facility
Sex Offender - Outpatient
HCBS Waivered Residential Services
Sex Offender - Residential
Homeless
Supported Employment
Hospice – Class D
Sober House
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State Operated Residential Treatment Facility for DD
Temporary Placement
State Operated Residential Treatment Facility for MI
Unknown
Supervised Living Facility
Living Arrangement or Programs/ Services received (check all that apply):
Children’s Settings
Children’s Services
Lives at home with parents/family
245D Home and Community Based services
Child Foster Care
Children’s Therapeutic Services and Supports
Foster Care Child – Department of Corrections
Early Intensive Developmental & Behavioral
245D Community Residential Setting
Intervention
Children’s Residential Facility
Adult Settings
Adult Services
Adult foster care
245D Home and Community Based services
245D Residential facility (ICF/DD)
Adult Day Center/Facility
245D Community Residential Setting
Family Adult Day Services
Intensive Residential Treatment (IRTS)
Adult Rehabilitative Mental Health Treatment
Board and Lodge
Services (ARMHS)
Board and Lodge with Services
Assertive Community Treatment (ACT)
Boarding Care Home
Residential treatment for adults with mental illness
Substance use disorder treatment – Residential
DBT provider (certified)
Housing with Services/Assisted Living
Behavioral Health Home
Nursing Home
Certified Community Behavioral Health Clinic
Supervised Living Facility
Mental Health Center
Own apartment/home
Substance use disorder treatment – Nonresidential
Shared Housing
Other Certified Treatment Provider
Homeless
Home Care Provider: Class A, Class B, Class C, Class F
Hospice – in facility
Hospice – in home
Lives with Relatives
Acute Care Hospital
Wet House
Other
Direct Care and Treatment Services / State Operated Services
Direct Care & Treatment - AMRTC
_____ Community Addiction Recovery Enterprise
Direct Care & Treatment - CBHH
Direct Care & Treatment – MSH
Forensic Nursing Home
Direct Care & Treatment – MSOCS
Direct Care & Treatment – CABHS
Minnesota Sex Offender Programs
Type of Injury
(check one):
Attempted Suicide
Concussion, no loss of consciousness requiring medical
Extensive Burns (second or third degree)
assessment
Complication of medical treatment
Heat Exhaustion or Sun Stroke
Complication of previous injury
Ingestion of poison or harmful substances
Dental Injuries (avulsion of teeth)
Internal Injuries
Dislocation
Laceration (muscle, tendon or nerve damage)
Eye Injuries
Multiple Fractures
Fracture
Near Drowning
Extensive Frostbite (second or third degree)
Other injury considered serious by Physician or
Head Injury with loss of consciousness
HealthCare Professional (including self-injurious
Potential Closed Head Injury
behavior, complications of treatment, delay of
treatment & medication error)
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Circumstances Surrounding the Serious Injury (check all that apply):
Client to client
Sports/activity related
Fall
Staff to client
Other – Describe
Restraint
Self-Injurious Behavior
Unknown
Injury Type Specifics:
Describe how the serious injury occurred:
\
Describe the medical attention received and when:
Describe any medication changes since the time of serious injury:
Describe any follow-up appointments, assessments or medical services needed since the serious injury:
Describe any changes to the abuse prevention plan or individual programing as a result of the serious injury:
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Describe any policies, protocols or staff training being implemented to address this issue:
DIAGNOSTIC INFORMATION
Psychiatric Diagnoses:
Developmental and Intellectual Disabilities and Personality Disorders:
Medical Conditions:
MEDICATIONS
(Use a separate sheet if necessary)
Current Medications
Dose
Frequency
Please attach supporting documentation
Complete this form and fax to 651-797-1950 or 651-296-1021
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