Client Name:	Client DOB:	Date of Last Service:
Client PSP No.:	Provider Site/RU:	Date & Time of Incident:
Primary Clinician:	Location of Incident:
Primary Diagnosis:
Known Allergies:
Current Medication(s): Please include Prescriber; Dose/frequency; Initial prescription date & Refills left:

What type of Services were provided by your agency?	MH or SUD Services
Description of Services:
Has a client death occurred?	Yes No If no, please skip to #5
PLEASE INDICATE CAUSE OF DEATH:
Suicide	Natural Causes	Homicide	Accidental
Secondary to Medical Condition:	Other/Unknown:
Narrative of Incident:
Injuries/Damages incurred:
Please list existing medical conditions:
Was an internal review of the case conducted by the provider site? YES NO If yes, please attach any associated report
Please attach and list other mandated reports made to other agencies:
Agency QA Staff to contact regarding report	Contact Phone Number
Name of person completing form (if different than above)	Contact Phone Number
Agency Name and Address	mm/dd/yy Date Form Completed

Please return completed form to:

Secure Email to: QAOffice@acbhcs.org	FAX: QA Administrator 510.639.1346	Mail: ACBHCS- QA Administrator 2000 Embarcadero Cove, Ste 400 Oakland, CA 94606