Attachment 8 - IHSC Incident Reporting Document.pdf

10. Work Related:

11. Weapons Involved:

6. (State in block # 16):

Page 1 of 210/2010IHSC Form 010

Incident Reporting Document ICE Health Service Corps

The information placed on this form is confidential and privileged IAW 42 U.S.C. 11137. UNAUTHORIZED DISCLOSURE CARRIES A FINE UP TO 20,000. DO NOT FILE OR REFER TO THIS FORM IN PATIENT RECORD. REPORT EVENT TO SUPERVISOR/DEPARTMENT CHIEF IMMEDIATELY. Email completed to: DIHSHQINCIDENTS@dhs.gov This Form must be completed electronically.

1. Date of Event: 2. Time of Event:

4. Age: 5. Gender:

7. Attending Medical Provider: 8. Location of Event:

9. Diagnosis (Medical/Psychiatric if any):

12a. Name of Witness:

13. Type of Incident/Ocurrence:

14. Condition After Occurrence (Check one box only):

Minor Injury or Effect Significant Injury or Effect Death or Loss of Function Other (Explain in narrative block # 16)

No Apparent Effect

Adverse Drug Reaction Airborne Exposure Bloodborne Exposure

Equipment Escape Fall/Discovered on Floor

Injury Medication (to include IV)

Medication Administration

Pharmacy Property Loss or Damage Suicide/Suicide Attempt Other (Explain in narrative block # 16)

Did Medical Provider See Patient

15. Action Taken

Other (Explain in narrative block # 16)

Infection Control Precautions Taken (Explain type of precaution in narrative block # 16)

Transported to Other Health Care Facility

Reported to Supervisor/ Department Chief

Laboratory Tests Ordered/Taken

X-Rays Ordered/Taken

Medical Provider Notified Yes No Yes No Yes No

16. Description of Event (Concise, Factual, Objective Statements), Include Location of Event:

17. Immediate Intervention (If more space is needed, use a blank sheet of paper for continuation):

21. Log Number: 22. Further Analysis Indicated:

3. Name of Facility:

Detainee Visitor OtherStaff

Yes No Yes No

Name, Grade, Title of Individual Completing Form (Print) Date of Report

12. Witnesses:

For HQ Use Only:

Yes No

Yes No

Country of Origin:A#:

First Name:Last Name:

Medical Clinic:

DOB:

Sex:

Date of Camp Arrival (DCA):

Signature

ICE Health Service Corps Incident Reporting Document (Continued)

Page 2 of 210/2010IHSC Form 010

22. Body Diagram:

HSA: Date:

Country of Origin:A#:

First Name:Last Name:

Medical Clinic:

DOB:

Sex:

23. Evaluation: (Concise Objective Statements e.g., Practice/Procedure variance involving staff. Include other possible contributing factors, etc. and suggested improvement measure if any):

Date of Camp Arrival (DCA):

Performance Improvement Committee: Date:

Medical Director: Date:

10. Work Related:

11. Weapons Involved:

6. (State in block # 16):

10/2010 IHSC Form 010 Incident Reporting Document ICE Health Service Corps The information placed on this form is confidential and privileged IAW 42 U.S.C. 11137. UNAUTHORIZED DISCLOSURE CARRIES A FINE UP TO 20,000. DO NOT FILE OR REFER TO THIS FORM IN PATIENT RECORD. REPORT EVENT TO SUPERVISOR/DEPARTMENT CHIEF IMMEDIATELY. Email completed to: DIHSHQINCIDENTS@dhs.gov This Form must be completed electronically.

13. Type of Incident/Ocurrence:

14. Condition After Occurrence (Check one box only):

Did Medical Provider See Patient

15. Action Taken Other (Explain in narrative block # 16) Infection Control Precautions Taken (Explain type of precaution in narrative block # 16) Transported to Other Health Care Facility Reported to Supervisor/ Department Chief Laboratory Tests Ordered/Taken X-Rays Ordered/Taken Medical Provider Notified Yes No Yes No Yes No

22. Further Analysis Indicated:

12. Witnesses:

For HQ Use Only:

ICE Health Service Corps Incident Reporting Document (Continued) 10/2010 IHSC Form 010

22. Body Diagram:

23. Evaluation: (Concise Objective Statements e.g., Practice/Procedure variance involving staff. Include other possible contributing factors, etc. and suggested improvement measure if any):

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