Unusual Incident/MUI Report Form

Champaign County Board of DD Incident Report

Report must be written within 24 hours or next business day of incident.

Individual's Name *

Date of Incident *

Time of Incident *

Date/Time of Discovery *

Time of Reporting *

Location of Incident *

PPI *

Description of Incident (Be specific and factual. Describe what happened before, during and after incident.) *

Witness to Incident *

Injury - Describe Type and Location *

Immediate Action Taken to Ensure Health and Safety *

* Indicates required field

By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge *

Nurse's Report (if applicable) *

By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge *

Program Coordinator / Supervisor / Director Comments: *

By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge *

SSA Comments *

By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge *

Submit

Champaign County Board of DD Incident Report

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