Internal Incident Report

Internal Incident Report

All incidents must be reported within 24 hours of the incident or within 24 hours of when the program became aware of the incident. A separate form must be completed for each person – do not use identifying information, such as names, if the incident involved another person receiving services.
Incident relates to:
Program
Location
Location of Incident if other than Affinity Site:

Street Address

Street Address Line 2

CityState

Zip Code
Name of Person Served

First NameLast Name
Date of Incident:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident:

Hour Minutes

AM/PM Option
Name of staff reporting incident:

First NameLast Name
Email of staff reporting incident:
example@example.com
Supervisor of staff person who responded to the incident:

First NameLast Name
Supervisor email
example@example.com
911 Emergency Services Used
Was this a "medical emergency, unexpected serious illness, or significant unexpected change in an illness or medical condition of a person that requires the program (Affinity) to call 911... for treatment; or hospitalization [Minn. Stat. 245D.02, subd. 11(3)]
Was this a behavioral incident that resulted in a call to 911;
Mobile Mental Health Crisis (COPE) called
(EUMR) Did Affinity staff use a manual restraint?
Was an as needed (PRN) medication used to intervene in a behavioral incident?
Is there Serious Injury?
Type of Serious Injury (Minn. Stat. 245.91, subd. 6)
Was there a Death?
Details of the Incident
External Property Management Company Summary (PPL)

A brief description of what happened, without identifying other persons served. 0/255
Staff Response to the Incident
Provide a description of the incident and staff response to the incident:
Do not use identifying information, such as names or initials, if the incident involved another person receiving services.
Were relevant policies and procedures followed?

Other
If no, explain.
Is the incident similar to past events with the persons or the services involved?
If yes, identify the incident patterns.
Is there a need for corrective action by the program to protect the health and safety of the persons receiving services and to reduce future occurrences??
If yes, identify the corrective action plan.
Were coordinated service and support plans applicable to the person and incident, implemented for the person(s) involved?

Other
Were Affinity Care - 245D policies and procedures, applicable to the incident, implemented as written?

Other
If other staff responded to the incident, please include their names:
Persons Notified
Case Manager:

First NameLast Name
Case Manager Email
example@example.com
Case Manager Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Date Notified:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time Notified

Hour Minutes

AM/PM Option
Legal Representative

First NameLast Name
Date Notified:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time Notified

Hour Minutes

AM/PM Option
Signature of reporting staff:
Date signed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Internal Incident Report

Details of the Incident

Staff Response to the Incident

Persons Notified