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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.

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Report Notification

This Report DOES NOT replace a DCF or KDADS Long Term Care Complaint Hotline Report.

Notice

Notice

Instructions 2

Complete the Incident Information in the regions below and click the Create button at the bottom of the page. Once the report is created, a File Uploads region will display so that you can attach any document(s) related to this report.

Report # Status & Date

Report Status: WORK IN PROGRESS Report Date: 06/19/2024

AIR Contents

Incident Information

Reporter Details

If unknown, type/select UNKNOWN.
Enter numeric digits only. Include area code.
Enter E-mail Address, if known.

Individual Details

Individual Involved in Incident
Enter date manually or click the calendar icon to select date from a pop-up calendar. If unknown, leave blank.
If unknown, leave blank.
If unknown, select the Unknown/Not Assigned option.

Incident Details

Enter date manually or click the calendar icon to select date from a pop-up calendar.
Enter approximate time in the format shown. If unknown, leave blank. Use the time component of the pop-up calendar or manually type in the time.
If unknown, select the UNKNOWN option.
If unknown, select the UNKNOWN option.
If unknown, select the UNKNOWN option.
If unknown, enter UNKNOWN. If not applicable, enter N/A.
Include relationship to individual - - For example: staff; family member (spouse; sibling; child, etc.)
If unknown, leave blank.
If unknown, leave blank.