REPORTABLE INCIDENT FORM - Tennessee Division of Mental Retardation Services

Name of Person ________________________________ Date/Time _______/______

Confidential, Please Print in Black Ink of incident
AM PM

Agency Reporting Description of Injury – must describe

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Support Coordination Agency of Person
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Description of Incident - (what/where/when/who)
type, size, location/body part, color of
injury; type & location of treatment; &
other relevant information.

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NAME TITLE DATE
________________________________ TIME
________________________________ Type of Incident [Check as many as apply]
This incident was ο Witnessed Alleged/suspected: ο Physical Abuse ο Sexual Abuse
ο Discovered ο Neglect ο Mistreatment ο Verbal Abuse
ο Death ο Serious Injury - Unknown Cause
Where Incident Occurred [Check one]
ο Fall ο Physical Aggression - Victim
ο Home – Inside ο Home - Outside
ο Other Accident ο Physical Aggression - Perpetrator
ο Vehicle ο Day
ο Self-Injurious Behavior ο Property Destruction over $50
Program/Work/School
ο Swallow Inedible ο Nonconsensual/Illegal
ο Community-Supervised ο Community-Unsupervised /Harmful Matter Sexual Activity
ο Unknown ο Choking ο Suicide Attempt
ο Elopement ο Elopement Attempt only
Address/Site of Incident _________________________ ο Insect/Animal Bite ο Seizure (status/injurious)
Responsible Agency, if different __________________ ο Unusual Physical Reaction ο Medication/Treatment Error
(allergic, adverse drug, etc.) (requiring medical treatment)
This Incident Required [Check all that apply]
ο Manual Restraint ο Mechanical Restraint ο OTHER _________________________________
ο Other Restraint ______________________________
ο Emergency Psychotropic Medication
Notifications
ο Copied Form (page 1) to Support Coordination Agency
ο Heimlich Maneuver ο CPR
ο 911 Call ο Mobile Crisis Team Date ________________ Time _________________
ο Hospital Emergency Room ο Hospitalization
ο Police ο DMRS Investigator Notified - when applicable
Injury [Check one] Date ________________ Time _________________
ο NO APPARENT INJURY
ο MINOR INJURY Name of Investigator__________________________
ο SERIOUS INJURY - injury requiring assessment/ ο Family/Legal Guardian/Conservator Notified
- when applicable
treatment by a physician, nurse practitioner, or
physician assistant - (Attach Medical Report) Date ________________ Time _________________

MH-0000 REV 06/01/00

 REPORTABLE INCIDENT FORM - Tennessee Division of Mental Retardation Services
Name of Person ________________________________ Date/Time _______/______
Confidential, Please Print in Black Ink of incident
AM PM

Person Reporting Incident

SIGN _______________________________________
PRINT (name/title) ______________________________
DATE/TIME reported __________________________

DMRS Incident Fax 615-253-4921 or 877-551-5591

Program Supervisor Review

PRINT (name/title) ____________________________________

SIGN _____________________________________________

DATE/TIME ________________________________________

Committee Review
Date _____________________
Discussion Issues (Include review of staff actions in response, current status of person served, possible
corrective/preventive actions)
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Actions Taken
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Follow-up Communication
ο with Independent Support Coordinator/Coordination Agency
Date __________________

ο with Family/Legal Guardian/Conservator

Date __________________

Incident Management Coordinator

MH-0000 REV 06/01/00

 REPORTABLE INCIDENT FORM - Tennessee Division of Mental Retardation Services
Name of Person ________________________________ Date/Time _______/______
Confidential, Please Print in Black Ink of incident
AM PM

PRINT (name/title) ____________________________________

SIGN _____________________________________________

DATE/TIME ________________________________________

MH-0000 REV 06/01/00