Exhibit A Unusual Incident Report (1).docx
DOCX document 35 KB Posted
- Attached to
- AZ|CTR079166
- Contract number
- CTR079166
- Issued by
- Arizona
About this file
This document is an Unusual Incident Report Form, a standardized template used by the State of Arizona for documenting and reporting incidents within state and local programs. The form does not identify a specific contracting agency or company; rather, it serves as a universal reporting mechanism applicable across Arizona government operations and contracted service providers.
The form requires reporting of unusual incidents within one business day of occurrence and captures essential incident information including agency name, program designation, date and time of occurrence, participants and staff involved, incident type, detailed description, witnesses, and immediate actions taken. The document specifies mandatory fields for personnel demographics, admission dates, and submitter identification, with instructions indicating that solicitation requirements are available online through the Arizona government portal. This form functions as an administrative reporting tool rather than a contract document and contains no pricing, service descriptions, payment terms, option periods, or financial provisions.
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Text version
Exhibit A - Unusual Incident Report Form
Solicitation No.:
Description:
Exhibit A - Unusual Incident Report Form
Directions: Please fill out this form within one business day of an unusual incident.
Agency Name:
Date:
Program:
Participants/Staff Involved:
Date Occurred:
Age:
Sex:
Date of Admission:
Type of Incident:
Describe Incident: (Please provide as much detail as possible)
Persons who observed incident:
Explain what immediate action was taken:
Report Submitted By:
Date:
Solicitation Requirements Available Online at https://app.az.gov image1.png image4.png image2.png
File details come from the government source that posted it. Updated .