ࡱ> nqm[@ }bjbj44 nViViq P| P|RRRRRR{{{{< }R~ BLOǹɹɹɹɹɹɹ$R8RE|RRc "RRǹǹߴhRRXt@ ~ GS{( G@<Wξ2ξ RRRRRRξRh_J<!RR`g RR`gRESIDENTIAL/COMMUNITY NOTIFICATION OF INCIDENT Select ONE box to the right and print either the License number OR Certification number. If dually licensed and certified, please check the box for the facility for which the incident is being reported. Only list ONE number.  FORMCHECKBOX  Residential Facility  (Lic #:  FORMTEXT       ) FORMCHECKBOX  Community Setting  (Cert #:  FORMTEXT       )a) Date of this report  FORMTEXT       / FORMTEXT      / FORMTEXT       b) Date of Discovery  FORMTEXT       / FORMTEXT      / FORMTEXT       c) Provider Generated Incident No.  FORMTEXT      d) Provider name:  FORMTEXT      e) Provider Telephone (include area code)  FORMTEXT      f) Name of ADAMH/CMH Board to Whom Incident was Reported  FORMTEXT      g) Provider E-Mail Address  FORMTEXT      h) Provider Address (street, city, state, zip)  FORMTEXT      i) Name/Title of Person to Contact Regarding Incident  FORMTEXT      j) Telephone No. if Different from Agency No. Above  FORMTEXT      k) Incident Date  FORMTEXT       / FORMTEXT      / FORMTEXT      l) Incident Time (If unknown, indicate as such)  FORMTEXT      : FORMTEXT        FORMCHECKBOX  AM  FORMCHECKBOX  PMw) Incident Type FORMCHECKBOX  Abuse and Neglect by Staff - including allegations (select one)  FORMCHECKBOX  Physical  FORMCHECKBOX  Verbal  FORMCHECKBOX  Neglect  FORMCHECKBOX  Sexual  FORMCHECKBOX  Defraud  FORMCHECKBOX  Use of Force  FORMCHECKBOX  Attempted Suicide  FORMCHECKBOX  Death of or caused by Client/Resident (check all that apply)  FORMCHECKBOX  Living in ODMH License Residential Facility  FORMCHECKBOX  Suspected Homicide  FORMCHECKBOX  Suspected Suicide  FORMCHECKBOX  Serious Bodily Injury or When Medical Intervention or Hospitalization is required (select one)  FORMCHECKBOX  Self-Inflicted Injury  FORMCHECKBOX  Physical Assault Injury  FORMCHECKBOX  Accidental Injury  FORMCHECKBOX  Unknown Cause  FORMCHECKBOX  Restraint Related Injury  FORMCHECKBOX  Illness/Medical Emergency (specify on line below)  Nature of Illness:  FORMTEXT        FORMCHECKBOX  Medications (select one)  FORMCHECKBOX  Error  FORMCHECKBOX  Adverse Reaction  FORMCHECKBOX  Involuntary Termination of Treatment  FORMCHECKBOX  Sexual Assault Was a minor involved in Sexual Assault?  FORMCHECKBOX  Yes  FORMCHECKBOX  Nom) Notifications Made (select all that apply)  FORMCHECKBOX  Affiliating Agency  FORMCHECKBOX  DYS  FORMCHECKBOX  ODMH  FORMCHECKBOX  BHO  FORMCHECKBOX  Family/Guardian  FORMCHECKBOX  ODJFS  FORMCHECKBOX  ADAMH/CMH Board  FORMCHECKBOX  Local Police  FORMCHECKBOX  OLRS  FORMCHECKBOX  CSB  FORMCHECKBOX  MR/DD  FORMCHECKBOX  Other Protective Agency  FORMCHECKBOX  Court  FORMCHECKBOX  ODH  FORMCHECKBOX  Probation Officer   FORMCHECKBOX  Other  FORMTEXT       Client/Resident Informationn) HIPAA-Compliant Identifier (No Names)  FORMTEXT      o) Age  FORMTEXT      p) Gender  FORMCHECKBOX  Male  FORMCHECKBOX  Femaleq) Race/Ethnicity  FORMCHECKBOX  A - Asian  FORMCHECKBOX  W - White  FORMCHECKBOX  B - Black/African American  FORMCHECKBOX  H - Hispanic  FORMCHECKBOX  M - Alaskan Native  FORMCHECKBOX  Unknown  FORMCHECKBOX  N - Native American/American Indian  FORMCHECKBOX  P - Native Hawaiian/Other Pacific Islander r) Was the Client/Resident?  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FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provider generated no. of other incident.  FORMTEXT       y) As a result of the selected incident type (select all that apply): 1. Was restraint and/or seclusion (as defined in OAC 5122-26-16) used and/or involved?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, Type:  FORMCHECKBOX  Seclusion - total min. this episode:  FORMTEXT        FORMCHECKBOX  Physical Rest. - total min. this episode:  FORMTEXT        FORMCHECKBOX  Mechanical Rest. - total min. this episode  FORMTEXT        FORMCHECKBOX  Involuntary Emergency Medications 2. Are criminal charge0h2hh6iiiitnbbZx$If $$Ifa$gd>$If$+$If^`+a$gd}2vkdr9$$Ifs400*   4   07*4 saef4iiiii,j^jjjuaULLFFL$If dh$If $$Ifa$gd>$+$If^`+a$gd}2kd;$$Ifs4,Fz 0*` `  4   07*    4 saef4jjjjjjjjjjjjjkk kkl l llll0l2l4lllllllllll߿߳y߳jj?h>>*CJUj>hhCJU!jh>*CJUmHnHu"j2>hh>>*CJU h>>*CJjh>>*CJUj=hhCJUjF=hhCJU h>CJjh>CJUj<hhCJU#jjll`mmmjxxxTkdA$$Ifs4,Fz 0*      `4   07*    4 saef4 $Ifgd> $Ifgd}2$If dh$If lll8m:mNmPmRm\m^m`mdmfmmmmnxlxnxxxxxxxxxxx4y6yRyTyVydyfyy̽Ӭߜߚߊzp`jChhCJUh>5>*CJ\jlAhhCJUj@hhCJUUj@hhCJU!jh>*CJUmHnHuj @h>>*CJU h>>*CJjh>>*CJU h>CJjh>CJUj?hhCJU%s against a client/resident being pressed by staff?  FORMCHECKBOX  Yes  FORMCHECKBOX  Nou) Was staff injured as a result of this incident?  FORMCHECKBOX  Yes  FORMCHECKBOX  Nov) Additional Information (No names, please):  FORMTEXT       z) Signature of Person Completing Form: Date:  FORMTEXT      / FORMTEXT      / FORMTEXT      Please fax completed form to the Board, and ODMH at 614-387-2987 or mail to ODMH at 30 E. Broad Street, 8th Floor, Columbus, OH 43215-3430, Attention: Standards Development & Rules Administration DMH-0484 DMH-LIC-015 Revised: 08/01/2006 x2yyyyyWF$+$If^`+a$vkdC$$Ifs400*   4  07*4 saef4 $Ifgd>$+$If^`+a$gdnTM$+dh$If^`+a$yyyyyyyzzzzzzz|z~zzzzzzzzzzzzzzzzϸŨϞߒyhߒVhߒ"jeFhh>>*CJU!jh>*CJUmHnHu"jEhh>>*CJU h>>*CJjh>>*CJUh25>*CJ\jhCJUmHnHujDh2CJUjh2CJU h2CJh>5>*CJ\ h>CJjh>CJUjChhCJUyzzzzznzI5$+dh$If^`+a$vkd2E$$Ifs400*   4  07*4 saef4 $Ifgd>$dh$Ifa$gdnTM$+dh$If`+a$$dh$If^`a$gd>nzpz|zzzz{B9 d$IfkdQG$$Ifs4Fi0*p       4  07*    4 saef4$If $$Ifa$$dh$If^a$gdYi$+$If^`+a$zzzzzzz2{P{{{{|(|||||||||||}}"rlh\Th+CJaJjh+CJUaJh+ h+CJhYi5CJOJQJ\^J hLCJh25>*CJ\!hnTMhnTM0JB*CJaJphh25CJH*\h25CJ\ hnTMCJ h2CJh>5>*CJ\ h>CJ!jh>*CJUmHnHujh>>*CJU"jFhh>>*CJU{|||||||_S $$Ifa$gd2vkd\H$$Ifs400*`   4   07*4 saef4$If $Ifgd2 d$If$+$If^`+a$|}}RޘusfVVI d$If^dh$If^gd+ d$If^$$If^`$dhvkdVI$$Ifs400* 4 07*4 saef4&1h:pp!/ =!"#h$%ʏ| |c*({( " "0({()((((((((|c*({4((((((((a(vDeCheck77tDText1tDeCheck2jD$$Ife!vh55555#v#v#v#v#v:V l407*,55555/  /  4aef4tDText3tDText4tDText5tDText3tDText4tDText5vDText12=$$Ifl!vh5( 5m 5 5 #v( #vm #v #v :V s1 (07*5( 5m 5 5 /  44 saep(tDText6tDText7$$Ifl!vh55#v#v:V s4^07*55/  /  /  / 44 saef4tDText8tDText9$$Ifl!vh55#v#v:V s407*55/  /  / /  44 saef4vDText16$$Ifl!vh57*#v7*:V s407*57*/ /  44 saef4vDText11vDText15$$Ifl!vh554#v#v4:V s4807*554/  /  / / /  44 saef4jDjDjDvDText19vDText20vDeCheck75vDeCheck76}$$Ifl!vh55 554#v#v #v#v4:V s407*+++55 554/  /  /  / /  / / / /  /  /  44 saef4vDeCheck79vDeCheck19vDeCheck20vDeCheck78vDeCheck21vDeCheck22vDeCheck80vDeCheck23vDeCheck24vDeCheck25vDeCheck26vDeCheck27vDeCheck81vDeCheck28vDeCheck29vDeCheck30vDeCheck31vDeCheck32vDeCheck33vDText14vDeCheck82vDeCheck34vDeCheck35vDeCheck36vDeCheck37vDeCheck38vDeCheck39X$$Ifl!vh55 554#v#v #v#v4:V s4\07*++++55 554/  /  / / / /  /  /  44 saef4tDeCheck3tDeCheck4tDeCheck5tDeCheck6vDeCheck10vDeCheck14tDeCheck7vDeCheck11vDeCheck15tDeCheck8vDeCheck12vDeCheck16tDeCheck9vDeCheck13vDeCheck17vDeCheck18vD2Text30$$Ifl!vh554#v#v4:V s4607*++554/  /  44 saef4$$Ifl!vh554#v#v4:V s407*++554/ /  44 saef4$$Ifl!vh554#v#v4:V s4v07*+554/  44 saef4vDText17$$Ifl!vh554#v#v4:V s407*+554/  44 saef4vDText18vDeCheck40vDeCheck41$$Ifl!vh5( 5 54#v( #v #v4:V s4L07*+5( 5 54/  /  / /  /  /  44 saef4vDeCheck42vDeCheck43vDeCheck44vDeCheck45vDeCheck46vDeCheck49vDeCheck47vDeCheck48$$Ifl!vh554#v#v4:V s4w07*+554/ /  / 44 saef4vDeCheck50vDeCheck51vDeCheck53vDeCheck83$$Ifl!vh554#v#v4:V s407*+554/ / /  /  /  44 saef4vDeCheck54vDeCheck55$$Ifl!vh554#v#v4:V s4Y07*++554/  /  /  44 saef4vDeCheck56vDeCheck57vDeCheck58vDeCheck59vDeCheck60$$Ifl!vh554#v#v4:V s407*+554/ /  /  /  44 saef4vDeCheck61vDeCheck62vDText29$$Ifl!vh5 5 54#v #v #v4:V s4,07*+++5 5 54/  / / /  /  44 saef4vDeCheck65vDeCheck66vDeCheck67vDText21vDeCheck68vDText22vDeCheck69vDText23vDeCheck70vDeCheck71vDeCheck72/$$Ifl!vh5 5 54#v #v #v4:V s4,07*+++5 5 54/  / / / /  /  /  44 saef4vDeCheck63vDeCheck64$$Ifl!vh554#v#v4:V s407*+554/  44 saef4vD,Text24$$Ifl!vh554#v#v4:V s407*+554/  44 saef4vDText26vDText27vDText28 $$Ifl!vh5p554#vp#v#v4:V s407*+5p554/  / /  / /  44 saef4$$Ifl!vh554#v#v4:V s407*++554/  /  /  / /  44 saef4$$Ifl!vh554#v#v4:V s407*+554/  / 44 saef4vDCheck77tDText1tDeCheck2jD$$Ife!vh  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFoHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklpstuvwxyz{|}~Root Entry F౦SrData GBWordDocumentn1Table({qr((((7<77p0|c*({@ " "a|c*({L " "a(({ar " " Oh+'0 $ 4@ \ h t /RESIDENTIAL/COMMUNITY NOTIFICATION OF INCIDENT1ESIODMHENTDMHDMHRESIDENTIAL.dotODMHENT1MHMicrosoft Word 10.0@F#@6@@Vj?Y[@ bjbj44 nViVid`2`24****<*,M- 3333h4B:L=KKKKKKK$MR PKB3|h4BBK33L IIIB:33KIBKIIII3- GS*B"I!IL<MI P C PI PI?h@JIP@<@!???KKdH"  FORMCHECKBOX  Residential Facility  (Lic #:  FORMTEXT       ) FORMCHECKBOX  Community Setting  (Cert #:  FORMTEXT       )a) Date of this report  FORMTEXT       / FORMTEXT      / FORMTEXT       b) Date of Discovery  FORMTEXT       / FORMTEXT      / FORMTEXT       c) Provider Generated Incident No.  FORMTEXT      d) Provider name:  FORMTEXT      e) Provider Telephone (include area code)  FORMTEXT      f) Name of ADAMH/CMH Board to Whom Incident was Reported  FORMTEXT      g) Provider E-Mail Address  FORMTEXT      h) Provider Address (street, city, state, zip)  FORMTEXT      i) Name/Title of Person to Contact Regarding Incident  FORMTEXT      j) Telephone No. if Different from Agency No. Above  FORMTEXT      k) Incident Date  FORMTEXT       / FORMTEXT      / FORMTEXT      l) Incident Time (If unknown, indicate as such)  FORMTEXT      : FORMTEXT        FORMCHECKBOX  AM  FORMCHECKBOX  PMw) Incident Type FORMCHECKBOX  Abuse and Neglect by Staff - including allegations (select one)  FORMCHECKBOX  Physical  FORMCHECKBOX  Verbal  FORMCHECKBOX  Neglect  FORMCHECKBOX  Sexual  FORMCHECKBOX  Defraud  FORMCHECKBOX  Use of Force  FORMCHECKBOX  Attempted Suicide  FORMCHECKBOX  Death of or caused by Client/Resident (check all that apply)  FORMCHECKBOX  Living in ODMH License Residential Facility  FORMCHECKBOX  Suspected Homicide  FORMCHECKBOX  Suspected Suicide  FORMCHECKBOX  Serious Bodily Injury or When Medical Intervention or Hospitalization is required (select one)  FORMCHECKBOX  Self-Inflicted Injury  FORMCHECKBOX  Physical Assault Injury  FORMCHECKBOX  Accidental Injury  FORMCHECKBOX  Unknown Cause  FORMCHECKBOX  Restraint Related Injury  FORMCHECKBOX  Illness/Medical Emergency (specify on line below)  Nature of Illness:  FORMTEXT        FORMCHECKBOX  Medications (select one)  FORMCHECKBOX  Error  FORMCHECKBOX  Adverse Reaction  FORMCHECKBOX  Involuntary Termination of Treatment  FORMCHECKBOX  Sexual Assault Was a minor involved in Sexual Assault?  FORMCHECKBOX  Yes  FORMCHECKBOX  Nom) Notifications Made (select all that apply)  FORMCHECKBOX  Affiliating Agency  FORMCHECKBOX  DYS  FORMCHECKBOX  ODMH  FORMCHECKBOX  BHO  FORMCHECKBOX  Family/Guardian  FORMCHECKBOX  ODJFS  FORMCHECKBOX  ADAMH/CMH Board  FORMCHECKBOX  Local Police  FORMCHECKBOX  OLRS  FORMCHECKBOX  CSB  FORMCHECKBOX  MR/DD  FORMCHECKBOX  Other Protective Agency  FORMCHECKBOX  Court  FORMCHECKBOX  ODH  FORMCHECKBOX  Probation Officer   FORMCHECKBOX  Other  FORMTEXT       Client/Resident Informationn) HIPAA-Compliant Identifier (No Names)  FORMTEXT      o) Age  FORMTEXT      p) Gender  FORMCHECKBOX  Male   FORMCHECKBOX  Femaleq) Race/Ethnicity  FORMCHECKBOX  A - Asian  FORMCHECKBOX  W - White  FORMCHECKBOX  B - Black/African American  FORMCHECKBOX  H - Hispanic  FORMCHECKBOX  M - Alaskan Native  FORMCHECKBOX  Unknown  FORMCHECKBOX  N - Native American/American Indian  FORMCHECKBOX  P - Native Hawaiian/Other Pacific Islander r) Was the Client/Resident?  FORMCHECKBOX  Victim  FORMCHECKBOX  Perpetrator  FORMCHECKBOX  Other FORMCHECKBOX  Use of Forcex) In addition, residential facilities shall also report, per OAC 5122-30-16: Occurrences Which Necessitate the Temporary Relocation of Residents and/or Require Emergency Medical Intervention  FORMCHECKBOX  Fire  FORMCHECKBOX  Disaster (e.g., flood, tornado, explosion) s) Others Involved (select all the apply) Another Staff  FORMCHECKBOX  Client/Resident  FORMCHECKBOX  Family  FORMCHECKBOX  Person  FORMCHECKBOX  Unknown "$&(PRThj~ܘޘ̹Ҭҙ}p}]p}JҬ$jh+5CJU\mHnHu%j Kh0.h+5CJU\jh+5CJU\h+5CJ\$jh+5CJU\mHnHu%jJhh+5CJU\jh+5CJU\$jh+5CJU\mHnHu h+CJh+5CJ\ h+CJjh+CJUaJ#j!Jh0.h+CJUaJ "$(,\^rtvęƙșҙԙƽƷo`jMh+>*CJU"jbMhh+>*CJU!jh+>*CJUmHnHu"jLhh+>*CJU h+>*CJjh+>*CJU h+CJh+5CJ\ h+CJ$jh+5CJU\mHnHujh+5CJU\%jKhh+5CJU\ޘ$*,Z?.$dh$If^`$kdK$$Ifl4rlX D)0*     07*4 laef4dh$If^gd+Zؙƚ dh$If$$If^`$gd++$If^`+gd+$dh$If^`$gd++$If^`+(*.0DFHRTVXlnpz|Țʚޚ024>@IJģ˙ˉyo˙by˙j[Qh+CJUh+5>*CJ\jh+CJUmHnHujOhh+CJUjh+CJUj2Oh+>*CJU"jNhh+>*CJU h+>*CJ h+CJ!jh+>*CJUmHnHujh+>*CJU"jJNhh+>*CJU%5$$dh$If^`$kdP$$Ifs1\! 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FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provider generated no. of other incident.  FORMTEXT       y) As a result of the selected incident type (select all that apply): 1. Was restraint and/or seclusion (as defined in OAC 5122-26-16) used and/or involved?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, Type:  FORMCHECKBOX  Seclusion - total min. this episode:  FORMTEXT        FORMCHECKBOX  Physical Rest. - total min. this episode:  FORMTEXT        FORMCHECKBOX  Mechanical Rest. - total min. this episode  FORMTEXT        FORMCHECKBOX  Involuntary Emergency Medications 2. 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