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Misconduct Incident Report

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Quality Assurance Wis. Admin. Code DHS (3)(a) F-62447 (05/2020) Page 1 of 8 Misconduct Incident Report GENERAL INSTRUCTIONS All Misconduct Incident Reports (MIR) must be submitted through the MIR system. Instructions regarding the access and use of the MIR system can be found on the DHS website. When access to the MIR system is not possible, this form may be used to Report incidents of alleged Misconduct (client abuse, client neglect, or misappropriation of client property) and injuries of unknown source. The Department reviews this Report to determine whether further investigation of the Incident is warranted.

photographs are taken, identify when the photos were taken, how many were taken and by whom. Describe any indication or expressions of pain, anger, frustration, humiliation, fear, etc. by the person during or after the incident. Explain what the entity did, upon learning of the incident, to protect the person(s) from further potential misconduct.

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