BHD 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 NotificationSelect
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
 
 
 
 
 
 
 
 
 
 
Notifications
ContactContact NameDate ContactedHow Contacted
Department of Family Services  
Protection and Advocacy  
Division  
Case Manager  
Guardian (if applicable)  
Law Enforcement Agency (if applicable)  
 
6101 Yellowstone Road, Suite 186E Cheyenne WY 82002 E-Mail: ddmail@health.wyo.gov • WEB site: http://health.wyo.gov/ddd Phone (307) 777-7115 • Toll Free (1-800) 510-0280 • Fax (307) 777-6047 • TTY (307) 777-5578