Public Adverse Incident Report Form

Adverse Incident Reporting Purpose

Effective incident management is essential to assuring the health and welfare of KDADS program participants. The Adverse Incident Reporting (AIR) System focuses on the identification and follow-up to critical events or incidents that bring harm, or create the potential for harm, to a KDADS program participant.
AIR focuses on critical events or incidents that the state itself deems as sufficiently serious to warrant near-term review and follow-up by an appropriate authority.

Notice

Hotline Phone Numbers and Information

Are you a Mandated Reporter?

Once the report is created, a "Upload Supporting Document(s)" Region will display to securely upload any documents related to the Incident.
The Report needs to be completed and submitted to KDADS prior to closing the window.
If you wish to retain a copy, print this form by using the "Print AIR Report" button provided below.

User Manuals:

Report Status:

WORK IN PROGRESS

Note:

Designates that the item is required.

Person Reporting Incident Information

Reporter To Remain Anonymous:

Yes

If "Yes" the Reporter information will only be housed with the State.

Report Completed By: First Name:

Last Name:

Reporter Phone:

Reporter Email (If Known):

Relationship to Individual Involved:

Service Provider Name (If Known):

Report Date:

09/25/2023

Report Submitted Date:

Individual Involved in Incident Information

First Name:

Last Name:

Date of Birth (If Known):

Medicaid ID (If Known):

MCO Organization (If Known):

Program Type:

Service Received During Incident (If Known):

KAMIS Person Number (If Known):

Incident Information

Incident Date:

Time of Incident (If Known):

County Where Incident Occurred (If Known)::

List person(s) Involved in Incident::

Include relationship to individual - - For example: staff; family member (spouse; sibling; child, etc.)

Adverse Incident(s) Click on the Incident Link to see the detailed definition.
This Report DOES NOT replace a DCF or KDADS Long Term Care Complaint Hotline Report

Other Explanation:

Reported to Appropriate State Agency:

YES

UNKNOWN

Which Agency Contacted:

DCF Adult (APS) / Child (CPS) Protection Services

KDADS Long Term Care Complaint Hotline

Date Notified (If Known):

Intake Number (If Known):

Incident Details

Summary of Facts Relevant to Incident:

Results of Incident (Transport to hospital, Outpatient Medical Treatment, Law Enforcement Involvement, Screen Requested, Transferred, Other):

Added On:

Modified By:

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