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Division of Behavioral Health Services Adverse Incident Report - Supplemental

Division of Behavioral Health Services Adverse Incident Report - Supplemental 2025

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The document is a supplemental information report for adverse incidents within the Department of Health Services' Division of Behavioral Health Services. It includes sections for incident details, client information, actions taken since the initial report, and signatures from various agency personnel. The purpose is to document additional findings and follow-up actions related to an adverse incident involving a client.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Date of Incident' and 'Client Name' in the designated fields. Ensure accuracy as this information is crucial for tracking.
Fill in the 'Date of Initial Report', 'Age', 'DOB', and 'Avatar #' to provide comprehensive client details.
Complete the sections for 'Agency/Facility/Program', 'Assigned Worker', and 'Supervisor'. This helps identify responsible parties.
In the section for additional information, document any new findings or actions taken since the initial report. This ensures all relevant data is captured.
Gather signatures from the Agency Designee, County Program Coordinator/Contract Monitor, County Program Manager, and County Division Manager. Each signature must be dated.
Finally, review all entries for completeness before submitting your report through our platform.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (45 Votes)
2018	4.8 Satisfied (250 Votes)
2015	4 Satisfied (41 Votes)
2009	4.3 Satisfied (43 Votes)

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What is a supplemental incident report?

0:06 1:37 Or have not yet been resolved. They can also be used to update information in tort proceedings orMoreOr have not yet been resolved. They can also be used to update information in tort proceedings or insurance claims.

What are the 4 types of incident reports?

Incident reports can be categorized into four main types: injury, illness, near miss, and property damage. Each type serves a specific purpose and provides valuable insights into different aspects of workplace safety.

What does it mean to supplement a report?

A Supplemental Report is utilized to augment an Incident Report. Supplemental Reports shall be utilized to document changes in the original Incident Report URN and/or record additional information pertinent to the Incident Report.

What is the difference between an incident report and a supplemental report?

After an incident report has been finalized by the Records department, a supplement can be created that contains all information from the original report. This supplement can be edited to adjust, add, or remove information that appeared in the original report.

What is an adverse incident report?

An adverse incident is an event or circumstance that might give rise to a claim, complaint or allegation against you. With claims-made protection, you are required to report an adverse incident to Medical Protection as soon as reasonably practicable after it occurs (or when you become aware that it has occurred).