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Indiana Family and Social Services Administration

Division of Aging

Non-Waiver Client Incident Reporting Tool



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.


General Section


You are filling out this form to report (choose the primary description):




The customer is:



On what date did the incident occur?       On what date did you become aware of the incident?

Reporting Party Information (i.e., about you)

Relationship to customer:






Your First Name       Your Last Name
Your Telephone       Your Email

Provider Information

Check this box if this incident related to a provider:  

Name of Provider 
Provider Address 
Provider City      Provider State 

Customer Information (i.e. about the person involved in the incident)

Main Funding Source Involved




Customer is:         Customer First Name       Customer Last Name
Customer Social Security Number       Customer Date of Birth (as mm/dd/yyyy)
Address

NOTE: At least the customer's City or ZIP or County is required

City       State       ZIP
County

Narrative

What service(s) was the customer receiving during the incident?


Explain the incident or complaint being reported.
If this is a death, explain the circumstances immediately before, during, and immediately after the death.

Corrective Action

What is the plan for corrective action or resolution of this incident?