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Ddd 0191a incident report

DDD-0191A - Incident Report 2025

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The document is an Incident Report form from the Arizona Department of Economic Security's Division of Developmental Disabilities. It is designed for Qualified Vendors to report incidents involving members, including details about the incident, individuals involved, medication administration errors, and any actions taken. The form emphasizes confidentiality and requires electronic submission. It includes sections for reporting incidents related to medication errors, member deaths, and other types of incidents, along with necessary notifications to relevant parties.

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Click ‘Get Form’ to open the DDD-0191A - Incident Report in our editor.
Begin by filling in the 'Date of Incident' and 'Time of Incident' fields. Ensure accuracy as this information is crucial for reporting.
Enter the Member’s details, including their name, date of birth, and AHCCCS ID. This section is vital for identifying the individual involved.
Indicate if the Member is in Foster Care and whether a Behavior Plan is required. If applicable, confirm if the Behavior Plan is current.
Complete the sections regarding the Vendor or Independent Provider responsible at the time of the incident, including their contact information.
For incidents related to medication, provide detailed descriptions in the Medication section. Include any errors or unusual occurrences during administration.
Finally, review all entries for completeness and accuracy before submitting your report electronically through our platform.

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Versions	Form popularity	Fillable & printable
2023	4.3 Satisfied (52 Votes)
2018	4.2 Satisfied (47 Votes)
2010	4.7 Satisfied (27 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can a guardian obtain a copy of an incident report from DDD?

What are the five rules of incident report writing? Timeliness: Always report the incident as soon as possible. Accuracy: Make sure all information provided is accurate and detailed. Completeness: Be thorough and provide all important details. Confidentiality: Handle sensitive and personal information carefully.

What are the four types of incident reports?

A guardian can obtain a copy of the incident report if they request it from DDD.

When must Level A incidents be reported to the DDD?

Level A incidents must be reported to DDD within 24 hours of occurrence. This requirement ensures that incidents are promptly addressed to protect participants and improve care quality. Providers are responsible for completing the necessary reporting forms to comply with these regulations.

When should an incident report be reported?

When should an incident report be written? Immediately after the incident. Within 24 hours of the incident. Within a week of the incident. Date, time, and location of the incident. Description of the incident. Names and contact information of witnesses. Any injuries or damages. Use clear and concise language.