Transcription of Unusual Incident Report Form (UIR)
1 1275 Lakeside Ave. (440) 333-MUI1 - HOTLINE. Cleveland, Ohio (216) 736-2669 - MUI Coord. (216) 241-8230 Main (216) 736-3399 - MUI FAX. Unusual Incident Report form (UIR). Individual Name: DOB: Address: City/County: Incident Date: Incident Time: Location: Description of Incident (Who, What, Where, When): Additional Page attached Injury Describe Type and Location: Actions Taken to Ensure Health & Safety: Name(s) of PPI: DOB: Relationship to Individual: Witnesses to Incident : Others involved: NOTIFICATIONS. Name/Title Relationship/Agency Date Additional Information Further Medical Follow-Up: Administrative Action: Signature: PRINT Name: Date: CCBDD UIR 03/30/10.
