FSSA - Division of Mental Health and Addiction (DMHA)
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Agency/Provider Information
Hospital:     Incident Date:
 
Incident and Setting Types
Incident Type:
Serious bodily injury to patient or employee on duty
Major disruption of service due to natural or other disaster
Incident which involves a criminal investigation or causes concerns for patient security
Emergency Hospitalization
Alleged abuse of a patient*
Major disturbance by patient or on-duty staff in community
AWOL*
Abduction of patient
Legal action or serious allegation against staff member
Death
Other
Individual Medical and Legal History
 
First Name:
Last Name:
Middle Name:
Age:
Sex:
Role:
Select Race(s):
.
 
First Name:
Last Name:
Middle Name:
Age:
Sex:
Role:
Select Race(s):
.
Description and results of incident:
Report Submission
Notification to DMHA
DMHA Representative Notified:
Date of Notification:
Notification Method:
Email Address: Office Telephone: Cell Phone:
Person completing form
First Name:   Last Name:   Middle Name:
Date Completed/Signed:
Name of Agency Contact for DMHA follow-up
First Name:   Last Name:   Middle Name:
Email Address:   Telephone: