Information Management for Providers

BHD INITIAL NOTICE OF INCIDENT

INCIDENTS MUST BE REPORTED IMMEDIATELY AFTER TAKING ACTIONS TO ADDRESS PERSON'S HEALTH AND SAFETY NEEDS.

Instruction: Please DO NOT use initials & abbreviations in narrative and for agency names. File a separate incident for each participant involved (except mass emergency), then please call the division immediately!

Participant Information

Client First Name		Client Middle Name
Client Last Name		Waiver
Date of Incident		Location (City)
Date of Report		Person Reporting
Phone		Email
Title or Relation To The Client

Provider Information

Service		If other, please specify:

Organization		If other, please specify:
Provider/ Staff Name		Provider/ Staff Phone
Did this incident occur while participating in remote support service?		YesNo


		Duty to Report:

	Adult Protection Services Act



	Child Protection Services Act

Incident Description

Click for Definition

Incident Type

DFS Notification

Select

Suspected Abuse

Required

Suspected Self Abuse

Required

Suspected Neglect

Required

Suspected Self Neglect

Required

Suspected Exploitation

Required

Suspected Abandonment

Required

Death

Required

Intimidation

Required

Sexual Abuse

Required

Police Involvement

N/A

Crime Committed By Participant

N/A

Injuries Caused By Restraints

N/A

Serious Injury

N/A

Elopement

N/A

Medication Error

N/A

Use of Restraint

N/A

Medical/Behavioral Admission

N/A

Other Injury

N/A

Preceding Events


Description of Incident

Actions Taken

Get DFS Contact Info

Notifications
Contact	Contact Name	Date Contacted	How Contacted
Department of Family Services
Protection and Advocacy
Division
Case Manager
Guardian (if applicable)
Law Enforcement Agency (if applicable)

* Note: After you select "Submit" you will go to a Confirmation page where you will be able to Print the Incident Report.

Herschler Building, 122 W. 25th Street, 4 West, Cheyenne, WY 82002 E-Mail: ddmail@health.wyo.gov • WEB site: https://health.wyo.gov/healthcarefin/dd/ Phone (307) 777-7115 • Toll Free (1-800) 510-0280 • Fax (307) 777-6047 • TTY (307) 777-5578

Select Location:
Address:
ZIP Code:
Phone:
Hours:

DFS Contact Information