Supervisor completes the top section and the employee completes the bottom section. Supervisor should email completed form and any additional information/documentation to the FSD MWA Coordinator and MWA Field Manager. Please indicate in the email if the event report is urgent or if a response is requested.
EMPLOYEE NAME	JOB TITLE	PROVIDER
SUPERVISOR NAME	MWA REGION	LOCATION WHERE EVENT OCCURRED
DATE/TIME OF EVENT	DATE REPORT SUBMITTED TO FSD	AFFECTED CUSTOMER NAME/DCN(S)
DESCRIPTION OF EVENT (COMMENTS AND/OR ACTIVITIES)
DESCRIBE IMPACT OF THE EVENT TO THE CUSTOMER, MISSOURI WORK ASSISTANCE PROGRAM, WORKPLACE, CLIENTS, ETC.
HAVE THERE BEEN FOLLOW-UP ACTIONS, SIMILAR OCCURRENCES, OR OTHER RELATED EVENTS, ETC?) YES NO IF YES, PLEASE DESCRIBE BELOW AND/OR ATTACH COPIES OF ANY ADDITIONAL INFORMATION.
WERE OTHER INDIVIDUALS OR AGENCIES INVOLVED? If yes, provide names/contact info	IF APPLICABLE, WERE THERE ANY OTHER OBSERVERS? Provide names/contact info
IF APPLICABLE TO THE EVENT: If there were other individuals involved or who observed this event, encourage them to provide a handwritten statement including a description of the event, their signature and the date the statement was written. Please provide names/contact information. NOTE: Any statements are confidential and will not be provided to anyone without a business-related need to know, unless there is a signed release.
SUPERVISOR SIGNATURE	TITLE	DATE
EMPLOYEE OBSERVATIONS: Complete this section and return it to your supervisor.
IS THE DESCRIPTION ABOVE COMPLETE? PLEASE PROVIDE ANY ADDITIONAL INFORMATION OR OBSERVATIONS.
EMPLOYEE SIGNATURE	DATE