INNOVATIONS INCIDENT REPORTING FOR FAILURE TO PROVIDE BACK-UP STAFFING For Semi‐Monthly Period Covering:
Name of Provider Agency: Date:
Individual Name and DOB:
_________________________ Service:
# of Hours
MCO: __________________________ Reason:
Name/Credentials of Person Completing This Form: _________________________________________
Comment, if “Other”:
Contact Number: ______________________
North Carolina Department of Health and Human Services (NCDHHS)