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Washington State Department of Social and Health Services
Aging and Long-Term Support Administration
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Residential Care Services Online Incident Reporting
Online Incident Report
Reporter/Fac. Information
Involved Individuals
Incident Details
Verify & Submit
Online Incident Report
*
Incident Report Type:
Follow-up to previous report
Resident-to-Resident or Client-to-Client
Staff-to-Resident or Staff-to-Client
Injury of unknown source
Resident or Client Fall
Financial Exploitation or Misappropriation
Medication error
Elopement or Missing Resident or Client
Any other type of Resident or Client related incident
Reporter Information
*
First Name:
*
Last Name:
Nickname:
*
Job Title:
Callback Number:
Nickname:
Facility Information
*
Facility/Agency Type:
Adult Family Home
Assisted Living Facility
Enhanced Services Facility
Intermediate Care Facility for Individuals with Intellectual Disabilities
Nursing Home
Supported Living
*
License/Cert. Number:
*
City:
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