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- Click ‘Get Form’ to open the DHHS Incident and Death Report NC 2006 form in the editor.
- Begin by entering the Provider Agency Name and Consumer’s Name at the top of the form. Ensure accuracy as this information is crucial for identification.
- Fill in the LME Client Record Number, which helps track the consumer's history within the system.
- Complete sections regarding consumer details such as Date of Birth, Gender, Ethnicity, and whether they receive CAP/MR-DD Waiver services. Use checkboxes for ethnicity options.
- Document the Time of Incident and Date of Incident accurately. This information is vital for timely reporting.
- In the Description of Incident section, provide a detailed account including who was involved, what happened, when it occurred, where it took place, and how it unfolded. Attach additional pages if necessary.
- For injuries sustained during the incident, circle locations on provided figures to indicate any bruises or marks.
- Once all sections are completed, review your entries for accuracy before submitting through our platform to ensure compliance with reporting requirements.
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