Incident Reporting Form Instructions
Please note that this incident Reporting Form does not replace the abuse, neglect and exploitation reporting required by state law and rule and must always be immediately reported to the Florida Abuse Hotline at 1-800-962-2873.
Critical Incidents must be reported to the NURTEC’s Office immediately upon being made aware of the incident. The initial report may be made via telephone, however, an Incident Reporting Form must be filled out and submitted no later than one business day after initial reporting.
Reportable Incidents must be reported to the NURTEC’s Office within one business day through the completion of the Incident Reporting Form.
Initial Report or Follow-Up Only: Check the box relevant to the Incident. If this is the first report being completed for an incident, check INITIAL REPORT, complete the Incident Data section, complete Section 1, and then scroll down to Submit Report. If there is follow up information regarding an incident, check FOLLOW-UP ONLY, complete the Incident Data section and then scroll down and complete the second section of the report. All follow-up must be noted on the second section.
PERSONS INVOLVED: List the name of all individuals involved in the incident, their Date of Birth, Sex, Personal Identification Number (Medicaid ID, Employee ID, Private Client ID, etc.), and their relationship to NURTEC (NURTEC Client, Nurtec Employee, Facility Employee, etc.).
DATE OF INCIDENT: The date the incident occurred.
TIME OF INCIDENT: The time the incident occurred.
COUNTY: The County in Florida that the incident occurred.
HOTLINE CALLED: Check if the Abuse Hotline was called as a result of the incident.
LAW ENFORCEMENT INVOLVED: Check if Law Enforcement was involved in the incident. This may include law enforcement called and/or law enforcement responded to incident.
GUARDIAN/ LEGAL REP. NOTIFIED: Check if the individual’s guardian or legal representative was notified.
DCF NOTIFIED (IF IN DCF CUSTODY): Check box if DCF was notified. Only notify DCF if the individual involved in the incident is in DCF custody.
DESIGNEE NOTIFIED: Check box if this incident was reported to NURTEC designee.
OPEN COURT CASE: Check box if the involved individual has an open court case that is pending action.
Incidents in this category must be reported to NURTEC within 1 hour upon becoming aware. If the incident occurs between the hours of 8:00p.m. and 8:00a.m., the incident must be reported no later than 9:00a.m. Select the category that applies to the incident being reported.
UNEXPECTED CLIENT DEATH: The death of an individual due to an unexpected incident. Examples may include, but not limited to, trauma, stroke, drug overdose, homicides, motor vehicle accident, etc.
LIFE THREATENING INJURY: The severe injury involving a substantial risk of death, loss of or substantial impairment of body. This may also include serious illness that may be a result of Abuse, Neglect, or Exploitation. This may include but not limited to
SEXUAL MISCONDUCT: Any sexual activity, as described in s. 393.135, F.S., that occurs between client and a provider (Regardless of consent), incidents of non-consensual sexual activity between clients or any other non-consensual sexual activity involving a client.
MEDIA INVOLVEMENT: An unusual occurrence or circumstance that may initiate unfavorable media attention.
VIOLENT CRIME ARREST: The arrest of a client with violent charges. Violent charges include, but not limited to, aggravated assault, assault and battery, domestic violence, homicide, manslaughter, murder, terrorism or forcible rape.
PROVIDER ARREST: The arrest of a facility employee for a potentially disqualifying offense, pursuant to Section 393.0655, F.S.
VERIFIED ABUSE REPORT: A protective investigation from the Department of Children and Families (DCF) that verifies a provider or provider staff has committed an act of abuse, neglect and/ or exploitation as defined in Chapter 39 F.S. and Chapter 415 F.S., of a client. If a provider is made aware of an abuse investigation with verified findings, the provider shall submit incident report immediately.
MISSING CHILD OR ADJUDICATED INCOMPETENT ADULT: The unauthorized absence or unknown whereabouts, for more than one (1) hour, of a minor or an adult who has been adjudicated incompetent. It is at the sole discretion of the provider to report the person missing prior to the one hour to local law enforcement and NURTEC Regional/Field office.
Incidents in this category must be reported to NURTEC within one (1) business day upon becoming aware. Select the category that applies to the incident being reported.
EXPECTED CLIENT DEATH: A client death that is considered “natural” from long-standing progressive medical conditions or age-related conditions. This includes, but not limited to, end stage cancers, heart disease, individuals in hospice care, etc.
ALTERCATION: A physical confrontation occurring between a client and a member of the community, a client and provider, or two or more clients at the time services are being rendered and that results in law enforcement contact.
CLIENT INJURY: An Injury sustained or allegedly sustained by a client due to an accident, act of abuse, neglect or other incident occurring during the times/he is receiving services from an NURTEC provider that requires medical attention in an urgent care center, emergency room, or physician office setting.
MISSING COMPETENT ADULT: The unauthorized absence or unknown whereabouts beyond eight hours of a legally competent adult client receiving services from an NURTEC provider.
- If the person is known to lack capacity to make safe decisions, it is the sole discretion of the provider to report the person missing prior to the eight hours to NURTEC and law enforcement.
SUICIDE ATTEMPT: An act which clearly reflects the physical attempt by a client to cause his or her own death.
BAKER ACT: The involuntary admission of a client of NURTEC to a receiving facility for involuntary examination or placement, and individuals authorized to initiate a Baker Act defined within Chapter 394 F.S.
NON-VIOLENT CRIME ARREST: The arrest of a client, which occurs while a client is under the direct care of a licensed or contracted provider, or Medicaid Waiver providers as a result of a non-violent crime. E.g. drug related charges, loitering, failure to appear, etc.)
ER VISIT/ HOSPITILIZATION: Any illness that requires a client to receive treatment at an Emergency Room, Urgent Care, and/or a Hospital.
INCIDENT LOCATION: Check the location the incident occurs. There should only be one check box checked.
FACILITY INFORMATION: The information completed in this field should be the facility information where the incident occurred. Do not use abbreviations in Name or Address, include the Area code for the phone number and complete the date of the report completed.
DESCRIPTION OF EVENT: Provide a complete narrative description of the incident. This includes, but is not limited to, persons involved, what happened, when the incident happened, where the incident happened, how the incident happened, and any treatment or actions taken immediately by provider and others involved.
PERSON REPORTING: The person filling out the Incident Reporting Form. Include direct phone number with area code.
Follow-Up Reporting Form Instructions
Please note this form may be completed at a later date from the initial Incident Reporting Form.
DATE OF FOLLOW-UP REPORT: The date the follow up report is completed.
FIRST TEXT BOX: Describe follow-up measures taken after Initial Incident Report was complete by the provider.
SECOND TEXT BOX: For NURTEC office use. Describe follow-up measures taken after Initial Incident Report was complete by the NURTEC office.
REPORTING PERSON: The person filling out the Follow-Up Reporting Form. Include direct phone number with area code.