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Service Provider Special Incident Report 2026
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- Click ‘Get Form’ to open the Service Provider Special Incident Report in the editor.
- Begin by entering the Client Name, Date of Birth (DOB), and UCI# in the designated fields at the top of the form.
- Fill in the HRC Service Coordinator and Service Provider details, including Vendor #.
- Specify the Date and Time of Incident, then select the Place of Incident from the provided options.
- Indicate the type of incident by checking all applicable boxes under INCIDENT TYPE. Provide additional details as required.
- For each section regarding injuries, crimes, or other incidents, answer Yes or No where prompted and provide descriptions as necessary.
- Complete any additional information requested at the end of the form, including your name and title before submitting.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2017 | 4.8 Satisfied (58 Votes) |
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Related links
Please use the Incident Report to register an identified vulnerability with a software product to ensure proper notification procedures are enacted. A Change
Category A and B providers shall report all level II incidents, except deaths, that occur during the provision of billable services
California Code of Regulations, title 17, regulations for special incident reporting to incorporate definitions 833-421-0061 Email: info@dds.ca.gov