• Completion of DDS Electronic Incident Reporting Forms

Completion of DDS Electronic Incident Reporting Forms
Instructions for Use
Accessing the forms
The forms are now accessible from the DDS Website. To access them go to the following:
1. Go to the link on the DDS website (currently in the lower left hand side) labeled “For
Providers” (see below)
2. From that link select the link labeled “Provider Forms” (see below)
3. In addition to these instructions you will see the two incident reporting forms
a. DDS Incident Report form 255 eVersion
b. DDS Medication Error Report form 255m eVersion
4. “Click” on these links to access these forms.
5. Do a “Save As” from the File Menu to save them to your local computer.
Completing the Forms
1. Both forms are set up as electronic “fillable” forms. You can use your tab keys on your
computer to navigate from one field to the next to complete the forms. Many items such
as Injury Type, Injury Cause, Restraint Types, etc are able to be selected by clicking on
the respective check boxes next to the choices.
2. Make sure in filling out the forms to fill in all of the required information completely.
3. To save the form with the completed information do a “Save As” and “rename” the
saved document as follows: Consumer Last
NameFirstName_IncidentType_IncidentDate (YYMMDD format). Example:
DoeJohn_Restraint_090701.doc.
4. Until an electronic transmission methodology is developed these incident reports will
need to be printed and either mailed or faxed to the appropriate DDS office for data
entry and to the respective case manager.
Questions
If you have questions regarding how to use these forms please contact the following
individuals:
DDS North Region
Janet Boyd (janet.boyd@ct.gov) Phone: 860-263-2531
DDS South Region
Lisa Lockwood (lisa.lockwood@ct.gov) Phone: 203-294-5165
DDS West Region
Lillian Amena ( Lillian.amena@ct.gov) Phone: 203-806-8773
Do Not E-mail Electronic Incident Report forms now as this will be a HIPAA
violation