ATT014_SurvivorCCE_DisruptiveMember_IncidentReport SAMPLE.docx
DOCX document 164 KB Posted
- Attached to
- Solicitation - World Trade Center Health Program - Survivor Clinical Center of Excellence
- Solicitation number
- CDC-75D301-01-Solicitation-WTCHP
About this file
This document is a Disruptive Member Incident Report form for the World Trade Center Health Program (WTCHP), designed to document and manage incidents involving program members exhibiting disruptive behavior. The form captures comprehensive details about the incident, including the type of incident (such as violence, threats, or harassment), date and time, specific description, and interventions taken by the Clinical Center of Excellence (CCE) or Network Provider Network (NPN).
The form includes sections for documenting previous incidents, vendor intervention plans, and potential actions such as written warnings, behavioral agreements, anger management referrals, transfer options, telehealth monitoring, and potential member discharge. The report must be submitted via the CARE Portal within 3 business days of the incident and requires signature confirmation of accuracy. Additional follow-up may involve World Trade Center Health Program Member Services, with specific protocols for addressing and mitigating disruptive member behaviors while maintaining program continuity and participant engagement.
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Disruptive Member Incident Report Submit this form via the CARE Portal within 3 business days of the incident date to your CCE’s NIOSH WTC Member Services point of contact.[footnoteRef:2] After submitting the Incident Report via CARE Portal, send an email with the corresponding CARE thread number and nature of the incident (do not include PHI) to: wtc@cdc.gov [2: This is the best practice. If contract has different requirements, please ensure to follow contract requirements at a minimum. ]
For WTCHP Use Only Incident Report Number
Date of Report
Member Name
Member ID (911#)
Witness Name
Witness Staff Role
Witness Staff Phone
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.
| ICD-10 Code |
| Condition |
Treatment Description(s)
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) |
| Yes ☐ No ☐ |
Previous Incidents Were there prior incidents involving the member?
If yes, list prior incident dates and incident report numbers Yes ☐ No ☐
Are there reports related to the incident?
If yes, list the type(s) of document(s) in the section below. Attach to the Incident Report submittal in the CARE Portal.
Yes ☐ No ☐
| Have previous actions been taken to address disruptive behavior? If yes, please list below. |
| Yes ☐ No ☐ |
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/contract[footnoteRef:3] [3: Required in most situations prior to discharge.
** Contact the WTC Health Program Member Services and Enrollment Unit prior to submitting the Incident Report and inform them that a suspension is being considered. ]
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 ☐ |
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 | Phone Number |
| ___________________________ | ___________________________ | |
| Title | Organization |
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