ATT013_DisruptiveMember_IncidentReport (1).pdf

Disruptive Member Incident Report Controlled Unclassified Information

Submission Instructions: Submit this form via the CARE Portal to DL-WTCHP-MS within 3 business days of the incident date.1 After submitting the Incident Report via CARE Portal, send an email to wtchpmemberservices@cdc.gov referencing the associated CARE thread. The email should state ‘A Disruptive Incident Report has been sent via CARE thread XXXXX’. No additional information is to be provided in the email.

For WTCHP Use Only Incident Report Number

Date of Report

Member Name

Member ID (911#)

Witness Name

Witness Staff Role

Name of Preparer

Organization

WTC-Related Certifications

Describe any relevant WTC-Related and/or Medically Associated Certification(s) and ICD code(s) and any active treatment(s) the member receives through the Program.

1 This is the best practice. If contract has different requirements, please ensure to follow contract requirements at a minimum.

ICD-10 Code Condition

Treatment Description(s) mailto:wtchpmemberservices@cdc.gov

Description of the Incident

Please provide a detailed description of the incident, including the date and the time, and any interventions taken by the CCE/NPN.

Type of Incident (e.g., violence threats, harassment)

Incident Date Incident Time

Incident Description

Interventions taken by the CCE/NPN (if applicable)

Attached Documents

Vendor Internal Report Yes No

Police/law enforcement report Yes No

Behavioral agreement (if applicable) Yes No

Letter(s) or other written communications to the member Yes No

Other (describe below)

Previous Incidents

Were there prior incidents involving the member? Yes No If yes, list prior incident dates and incident report numbers

Are there reports related to the incident? Yes No If yes, list the type(s) of document(s) in the section below.

Attach to the Incident Report submittal in the CARE Portal.

Have previous actions been taken to address disruptive behavior? Yes No If yes, please list below.

Vendor Intervention Plan Select all that apply.

World Trade Center Health Program involvement requested Yes No

Written warning letter Yes No

Restrictions to write-only communications Yes No

Behavioral agreement/contract2 Yes No

Anger management/counseling Yes No

Transfer option offered Yes No

Has another CCE/NPN agreed to accept transfer? Yes No

If so, which CCE/NPN?

Telehealth monitoring/treatment visit offered Yes No

Temporary suspension or restrictions from facility** Yes No

CCE/NPN considering discharge of the member** Yes No

Other: Please describe the steps already taken, and steps planned to mitigate the disruptive behavior. Yes No

that a suspension is being considered.

Additional Comments

Point of Contact for Follow-Up Questions Please provide the name of the individual who may be contacted for any follow-up related to the incident.

Name Phone Number

Title Organization

Signature of Responsible Party

I have received and review the above information and hereby confirm that all information is an accurate report of the events that occurred.

Name

Title

Organization

Phone Number