This form is intended for reporting incidents involving FSSA Division of Aging clients who are not
on waiver programs (Aged and Disabled or Traumatic Brain Injury).
If you need to file an incident report for a Division of Aging client on a waiver program, or for any
client of the Division of Disability and Rehabilitative Services, click here.
If you need to file a follow-up report to a incident report you filed using this form, click here.
Required responses will be marked like this.
NOTE: At least
the customer's City or ZIP or County is required