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OCFS8021 (6/2013) PAGE 1 OF 2 NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES SERIOUS REPORTABLE INCIDENT FOOTBRIDGES TO HEALTH (B2H) HOME & COMMUNITY BASED SERVICES MEDICAID WAIVER PROGRAM
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How to fill out serious reportable incident form

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To fill out a serious reportable incident form, follow these steps:
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Start by providing the necessary details about the incident, such as the date, time, and location.
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Describe the nature of the incident and provide a brief summary of what occurred.
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Identify any individuals involved, including their names, roles, and contact information.
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Provide any supporting documentation or evidence related to the incident, such as photographs or witness statements.
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Outline the actions taken immediately following the incident, including any first aid or emergency treatments provided.
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Describe any subsequent actions taken to address the incident, such as investigations or disciplinary measures.
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Include any recommendations for preventing similar incidents in the future.
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Review the completed form for accuracy and completeness before submitting it.

Who needs serious reportable incident form?

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A serious reportable incident form is typically needed by organizations or individuals responsible for reporting and investigating such incidents. This can include healthcare facilities, workplaces, regulatory bodies, or law enforcement agencies.

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The serious reportable incident form is a document used to report any serious incidents that have occurred within an organization or facility.
Staff members or employees who witness or are made aware of a serious incident are required to file the serious reportable incident form.
The form typically requires detailed information about the incident including date, time, location, individuals involved, description of the incident, and any actions taken.
The purpose of the serious reportable incident form is to ensure proper documentation and investigation of serious incidents to prevent future occurrences and improve safety protocols.
Information such as date, time, location, individuals involved, description of the incident, and any actions taken must be reported on the serious reportable incident form.
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