INNOVATIONS INCIDENT REPORTS
Please provide factual information only. Fields in yellow are required to be completed. When submitted, this form will be routed to your supervisor for review and any necessary follow-up action. Be sure to complete each section of the form before submitting the report.
 
 General Information
THIS FORM IS ONLY FOR HOST HOME PROVIDERS OR FRE STAFF. NO ONE ELSE SHOULD USE THIS FORM TO SUBMIT INCIDENT REPORTS. ALL OTHERS MUST USE EVOLV.
Required FieldInnovations Reporting Provider 
Required FieldInnovations Reporting Provider Primary Contact 
Consumer Name 
Required FieldDate of Incident Pick
Time of Incident 
Duration of Incident 
Required FieldInnovations Cost Center 
Required FieldLocation 
Required FieldWas this incident directly observed? 
Required FieldType of Incident 
Required FieldBrief Description 
Infectious/contagious disease? 
Required FieldDate Written Pick
Required FieldWrite your name as the reporting person 

 Persons Notified
Nurse notified at the time of the incident? 
Nurse's Name 
Case Manager notified at the time of the incident? 
Case Manager's Name 
Parent/Provider notified at time of incident? 
Guardian/Parent/Provider's Name 
Other person notified at time of incident? 
Other Person's Name 

 Incident Description
Required FieldDescription of Incident (Factual Information Only) 
Required FieldDescribe the preceding events and environment 
Required FieldHow was the situation handled? 

 Control Procedure
Was a control procedure used? 
Starting Time 
Ending Time 
Did Safety Control Procedure last over 15 minutes? 
If yes describe efforts to contact DD professional 
Describe the procedure used 
Why was procedure used? 
Has the behavior occurred before? 
Is the behavior likely to recur? 
Is there a behavioral ISSP? 
Comments 
Suggestion for prevention