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

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

Notifications

Get DFS Contact Info

Contact

Contact Name

Date Contacted

Contact Method

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

Participant Information

Provider Information

Duty to Report

Incident Description

Notifications

DFS Contact Information