Incident Report To report an incident, please complete the form below. When reporting overdoses and/or life-threatening events, please be as detailed as possible including only factual information.Company(Required)Full Name of Person Involved in the Incident(Required)Residence Certification Status(Required)Please selectOKARR CertifiedNot CertifiedResidence NARR Level(Required)Please selectLevel ILevel IILevel IIILevel IVAddress of Incident(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Incident(Required) MM slash DD slash YYYY Approx Time of Incident(Required) Hours : Minutes AM PM AM/PM Type of Incident(Required) Arrest: staff/owner Relapse: staff/owner Overdose: non-fatal Overdose: resulted in death Death: other Life-threatening incident Arrest: resident Other (please explain) If other, please explainDescribe the incident(Required)What actions were performed?(Required)E.g. CPR, Narcan, 911, etc.What was this person's "drug of choice", if applicable?Were there any pertinent behaviors prior to the incident or overdose that you can recall? What were those behaviors?(Required)If called, how soon were emergency responders called and how long did it take them to arrive?Was anyone notified other than emergency responders?What has been or will be done to assess and address the community in the aftermath?Gender of Client/Staff involved, if applicableAge of Client/Staff involvedAre they an Oklahoma resident?(Required) Yes No If non-resident, which state did they come from?If non-resident, how long have they lived in Oklahoma?If non-resident, how did they come to Oklahoma?If resident, please list their outpatient providerPlease describe their last known contact with staffAttestation(Required) I attest that this form is accurate and correct to the best of my knowledgeYour Name(Required) First Last Your Signature(Required)
