Dss 3123-2025

1. Click ‘Get Form’ to open the DSS-3123 incident report in the editor.
2. Begin by entering the Facility Name and County in the designated fields at the top of the form.
3. Fill in the Date and Time of the incident accurately to ensure proper documentation.
4. In Section I, check all applicable reportable incidents that occurred, such as resident injuries or unknown whereabouts.
5. Provide a detailed Incident Description in Section III, including any injuries and first aid administered.
6. In Section IV, describe any actions taken following the incident, including medical treatments provided.
7. Identify individuals or agencies that provided care in Section V, ensuring to include their location.
8. Complete Section VI with the current status of involved residents or individuals.
9. Have the Administrator/Operator sign and date at the bottom of the form before submission.

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