HOME CARE SERVICES INITIAL NOTICE OF INCIDENT
 
INCIDENTS MUST BE REPORTED IMMEDIATELY AFTER TAKING ACTIONS TO ADDRESS PERSON'S HEALTH AND SAFETY NEEDS.
 
Instruction: Please DO NOT use initials & abbreviations in narrative and for agency names. File a separate incident for each participant involved (except mass emergency), then please call the division immediately!
Participant Information
 
   
       
     
   
   
Provider Information
   
 
   
 
  Duty to Report:
 
Adult Protection Services Act  
Child Protection Services Act
 
 
Incident Description
 
 
 
Click for DefinitionIncident TypeDFS NotificationSelectIncident Location
Suspected AbuseRequired  
Suspected Self AbuseRequired  
Suspected NeglectRequired  
Suspected Self NeglectRequired  
Suspected ExploitationRequired  
Suspected AbandonmentRequired  
DeathRequired  
IntimidationRequired  
Sexual AbuseRequired  
Police InvolvementN/A  
Crime Committed By ParticipantN/A  
Injuries Caused By RestraintsN/A  
Serious InjuryN/A  
ElopementN/A  
Medication ErrorN/A  
Use of RestraintN/A  
Medical/Behavioral AdmissionN/A  
Food PoisoningN/A  
 
 
 
 
 
 
 
 
 
 
Notifications
ContactContact NameDate ContactedHow Contacted
Department of Family Services    
Protection and Advocacy    
Division    
Case Manager    
Guardian/Representative/Power of Attorney    
Law Enforcement Agency (if applicable)    
Healthcare Licensure Survey    
Medicaid Fraud    
 
6101 Yellowstone Road, Suite 210 Cheyenne WY 82002 E-Mail: alice.zimmerman@wyo.gov • WEB page: http://health.wyo.gov/healthcarefin/medicaid/homecareservices.html Toll Free Phone (866) 571-0944 • Fax: (307) 777-8685
Incident Description Location: Other

Please add "Other" location description of incident below: