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RCOC Vendor SIR Form 11-4-05.doc

RCOC Vendor SIR Form 11-4-05.doc 2025

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The document is a Special Incident Report from the Regional Center of Orange County, detailing various incidents involving consumers, including potential abuse, neglect, medical errors, and other significant events. It outlines required information such as consumer details, types of incidents, immediate actions taken, and notifications to relevant agencies. The report emphasizes compliance with Title 17 regulations and aims to ensure consumer safety and well-being.

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Click ‘Get Form’ to open the RCOC Vendor SIR Form 11-4-05 in the editor.
Begin by entering the consumer’s name and sex in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the date of report, date of birth, and UCI number. These details help track incidents effectively.
Check all applicable boxes under 'Check Applicable' to indicate the nature of the incident. This section includes various categories such as verbal/non-verbal communication and types of injuries.
In the 'DESCRIPTION OF INCIDENT' section, provide a detailed account of what occurred. If more space is needed, attach additional pages.
Complete the 'IMMEDIATE ACTION TAKEN' section to document any actions taken post-incident. Include medical treatment details if necessary.
Finally, ensure that all required signatures are added at the bottom before submitting your form.

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