Toll Free Number:
Home Care Services
Assist ID #
Where did the incident take place?
Which site is the client located at?
None-Please Select a Location
Cinder, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Cottonwood, 1760 East Villa Dr. Cottonwood, AZ 86326
DTA, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Elder, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Fernwood, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Flagstaff, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Kingman, 4255 Stockton Hill Rd. Kingman, AZ 86409
Lockett, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Nabah'haa, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Phoenix, 1616 East Indian School Rd. Suite 460 Phoenix, AZ 85016
Prescott Valley, 2485 North Great Western Dr. Prescott Valley, AZ 86314
Sunny, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Treadway, 5200 E Cortland Blvd. Flagstaff, AZ 86004
Yuma, 183 East 24th Street Ste. 7 Yuma, AZ 85364
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Primary Staff involved
who was there from ABRiO?
Did anyone else see the incident?
What happened before the incident?
Description of Incident
e.g. Medication Error
Did the client require medical intervention?
(doctor's visit, urgent care, ER, hospitalization)
If medical intervention explain:
Was APS, DCS or Social Services contacted?
Date APS, DCS or Social Services contacted?
Time APS, DCS or Social Services contacted?
APS, DCS or Social Services Method of Notification?
Was Police, Fire, or Ambulance called?
Date police, fire, or ambulance called?
Time police, fire, or ambulance called?
If yes, please give name of officer's involved & report number
Officer Smith, report number 2014-005, taken by Guardian Ambulance
Was the Parent/Guardian Notified?
Name of Parent/Guardian Notified
Date of parent/guardian notification
Time of parent/guardian notification
Person making Notification
What is your name?
DDD QA Notified? (Supv. only)
Name of Quality Assurance Person Notified if applicable (Supv.)
QA Method of Notification? (Supv)
Date submitted to DDD (Supv)
Time submitted to DDD
Plese choose an AIMS Type
None- Please Select a Type
1 Accidental Injury/ Illness - First Aid needed only
2 Accidental Injury/ Illness - Hospitalization
3 Accidental Injury/ Illness - Medical Intervention
4 Accidental Injury/ Illness - No medical intervention
5 Attempted AWOL
6 AWOL (Crime/ injury)
7 AWOL (no crime/ no injury)
8 Community - Complaint
9 Community - Disturbance
10 Death - expected
11 Death - no provider present
12 Death - unexpected
13 Emergency Measures - Chemical, not part of plan
14 Emergency Measures - Chemical, part of plan
15 Emergency Measures - Physical, not part of plan
16 Emergency Measures - Physical, part of plan
17 Evacuation of program (weather/fire/utility)
18 Human Rights - violation of dignity, respect, personal choice
19 Legal - Medicaid Fraud, Client Exploitation, Provider Drug Use
20 Maladaptive Behavior - Any type (documentation only)
21 Maladaptive Behavior - Any type (In-Patient/ Hospitalization necessary)
22 Maladaptive Behavior - Physical Aggression (Created injury to others)
23 Maladaptive Behavior - Physical Aggression (No injury to others)
24 Maladaptive Behavior - Property damage (<$100)
25 Maladaptive Behavior - Property damage (>$100)
26 Maladaptive Behavior - Self Injurious (first aid/ medical attention necessary)
27 Maladaptive Behavior - Self Injurious, no injury
28 Med Errors - Wrong client, wrong dose, administered wrong
29 Medication Documentation - Client Refusal, life threatening
30 Medication Documentation - Client Refusal, not life threatening
31 Medication Documentation - Medication disposal
32 Medication Documentation Error
33 Missing Person - High Risk
34 Missing Person - Low Risk
35 Neglect - Imminent Danger
36 Neglect - Potential Danger
37 Other Abuse - sexual abuse
38 Other Abuse - verbal/ emotional or programmatic
39 Other/ Non-client Incident (involving emergency response personnel)
40 Other/ Non-client Incident (NOT involving emergency response personnel)
41 Physical Abuse - medical intervention and/or police
42 Physical Abuse - no medical intervention or police
43 Seizure (no known history)
44 Seizure (over 3 min. or physician's emergency protocol duration)
45 Seizure (under 3 min. or physician's emergency protocol duration)
46 Suicide - Attempt No Medical Attention Needed 3
47 Suicide - Attempt Requiring Medical Attention 2
48 Suicide - Completion
49 Theft - State Property <$100; Public/Personal Property < $25
50 Theft - State Property >$100; Public/Personal Property >= $25
51 Injury - Victim of Aggression (ED Tx/Hosp)
52 Injury - Victim of Aggression (1st Aid Only)
53 Victim of Aggression (No Injury)
54 Medication Documentation - Other
55 Victim of Theft - Property Destruction < $25
56 Victim of Theft - Property Destruction > $25
Investigation Needed? (Supv)
Incident ID # (Supv)
YYYYMMDD## e.g. 2014031901
What could of prevented the incident?
(facts only, no personal beliefs or opinions)
What steps are being taken to prevent the incident from happening again?
Address prevention, staff corrective action if applicable, client status, next steps
Date of Submitted Signature
Supervisor's Signature Date
Admin Signature Date
Please call the Abrio Care IR hotline: 928-526-7396
Please call the Abrio Living IR hotline: 928-526-7395
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