Special Incident Report (SIR)

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In an effort to identify trends and develop strategies to prevent and lessen the risks to consumer health and safety, the DDS and regional centers monitor occurrences of unfavorable events captured through SIRs.

As required by Section 54327 of Title 17 of the California Code of Regulations, vendors and long-term health care facilities must report occurrences of suspected abuse, suspected neglect, injury requiring medical attention, unplanned hospitalization, and missing persons, if they occur when a consumer is receiving services funded by a regional center (under vendored care).

In addition, any occurrence of consumer mortality or a consumer being the victim of a crime must be reported whether or not it occurred while the consumer was under vendored care.

IMPORTANT: You must have Adobe Acrobat 9 Standard in order to submit the form using the links below. If you do not have Adobe Acrobat 9 Standard, you may still complete the form, however you must save it and send by email attachment to  aguzman@elarc.org AND sir@elarc.org (The form MUST be sent to both email accounts!)

Complete a Special Incident Report

Complete a Death Special Incident Report

IMPORTANT NOTICE (September 30, 2014): MEDICATION ERROR DIAGNOSTIC TOOL

DDS has determined that due to a recent increase in medication error for individuals that have moved out of developmental centers the following medication error diagnostic tool must be used for all individuals in this population. Although this tool is only required by DDS for individuals that formerly resided in a developmental center, ELARC has determined that the tool should be used for all medication errors that take place under vendor care. Therefore, the following Medication Error Diagnostic Tool must be submitted with all medication error SIRs that take place under vendor care. ELARC is required to submit all of the tools to DDS on a monthly basis. If you have any questions regarding this tool, please contact ELARC’s SIR Coordinator at 626.299.4635. 

Click here for the Medication Error Report Diagnostic Tool in WORD format

Click here for the Medication Error Report Diagnostic Tool in PDF format