INCIDENT REPORT FORM:

Initial

Combined Initial and Final Follow up Info. Final

Please check only one box above.

Name of Facility

City State

Zip

Street

please include ODH Form 718)

Certain Injuries (OAC

310:675-7-5.1(i))

Utility Failure (more than 8 hours)

Misappropriation of Resident Property

Allegations of Abuse/Mistreatment

Death Other than by Natural Causes

Storm Damage

Fire

Allegations of Neglect

Injury of Unknown Source

Missing Resident

Communicable Disease (Call Infectious Disease (IDPR) for initial outbreak notification only at

(405) 426-8710. Updates not required for ongoing outbreak).

Suspected Criminal Act* Physical Harm*

*If Physical Harm and Suspected Criminal Act, indicate if Local Law Enforcement Agency

contacted in the 'Notifications Made' box at the right.

Part B

Description of Incident. Please include injuries sustained as well as measures taken to protect the resident(s) during

investigation. (500 characters max) If additional pages are needed, see the optional page below.

Relevant Resident History. Please include relevant resident history (i.e. cognitive status, fall risk assessment, relevant care plan

instructions prior

to this incident, etc.) (500 characters max) If additional pages are needed, see the optional page below.

Part C

For 5 day and final reports, please include a summary of the investigation (include investigative actions, findings and

causative

factors) and corrective measures implemented to prevent recurrence. (500 characters max) If additional pages are needed,

see the optional page below.

Failure to document credible protective/preventative measures at the time of initial reporting and/or failure to provide

evidence of

a thorough investigation with corrective measures on the final report may require the OSDH to perform

an onsite visit to

determine if acceptable measures are being taken to protect residents.

Oklahoma State Department of Health

Protective Health Services

ODH Form 283

Revised 07/2024

Notifications Made

(Check all that apply)

Physician

Family

Resident's Legal representative

DHS: Adult Protective Services

Local Law Enforcement

Agency Name:

Date:

Time:

Appropriate Licensing Board

Nurse Aide Registry

(ODH Form 718 Attached)

Attorney General

Other

Oklahoma State Department of Health

Long Term Care

123 Robert S Kerr Ave, Suite 1702

Oklahoma City, OK 73012-6406

p. (405) 426-8200

Person Completing Form

Incident Location

Staff Involved

Incident Type

(For allegations against nurse-aides or nontechnical services workers,

Please complete Parts A & B for 24-hour notifications. Include Part C for 5 day and final reports. All

incident reports/notifications may be submitted to toll free fax number 1-866-239-7553.

Incident Date

Resident(s)/Client(s)/

Facility ID

Address

Point of Contact Email

Part A