Property Incident Report Form - Excel

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Property Incident Report Form - Excel Powered By Docstoc
					                         VO - KS Critical Incident Initial Report Form
Member Demographics
Member last name:_____________________________             Member first name:______________________________
Member number:_______________________________              DOB:_______________________ Sex:     M      F
Primary Diagnosis
Axis I:____________ Axis I:____________ Axis II:_______________
Provider Information
Facility name:_________________________________        Facility Address:________________________________
Facility phone:_________________________________       ______________________________________________
Name of person reporting incident:_____________________________________ Date reported:________________
Incident Information
Date of incident:________________________________          Time of incident:_________________________________
Level of treatment at the time of incident: _____________________________________________________________
Location of incident:______________________________________________________________________________
Description of incident, including who, what, when, where, and how (Describe any preceding circumstances, resulting
harm to people, property damage, current medications and any other relevant information. Submit a separate
incident report form for each member involved/affected):

Signature of person completing form:___________________________________           Date:_______________________

  For Sentinel and Major events call CS @ 1-866-645-8216 and submit form within 24 hours of occurrence.
                      For all other events, submit form within 5 calendar days of occurrence.
                                 Submit form via Fax or Sigaba encrypted email to:
                                    ValueOptions Kansas - Quality Manager
                                               Fax # 785-338-9020
             Your regional provider relations representative -and-
            Please direct any questions to Chris Forshee at 785-338-9009

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Description: Property Incident Report Form document sample