A Special Incident Report (SIR) is a formal report that is filed with the regional center. Service providers/ vendors have the responsibility to report incidents to the regional center that impact a client’s health and/or safety while the client is receiving services or supports, or if the client is a victim of a crime, or dies, regardless of when or where the incident occurred. Click here for in-depth information.

Per CCR 17 §54327, the regional center must be notified verbally of an incident within 24 hours of occurrence and a written report received within 48 hours of the incident. ALL Special Incident Reports must be emailed or faxed to:

SIR EMAIL: SIR@westsiderc.org

SIR FAX NUMBER: (877) 254-6903

If you have any questions, please contact the WRC Risk Management & Mitigation Coordinator, Bernadette Smyth Daroca, via email at Bdaroca@WestsideRC.org or via phone at (310) 258-4221.

The forms below can be used to meet reporting requirements. Service providers/ vendors must fill in the appropriate document, sign it, and submit the completed report via email (preferred) or via fax. An electronic signature is accepted for the Special Incident Report (SIR) via Adobe PDF. Please make sure that the submitted document(s) are legible. 

When you email the SIR, the email MUST be signed and encrypted to stay in compliance with HIPAA regulations. Include who you made a verbal report to at WRC and the date. This method should be used if you have already reported an SIR to a service coordinator (SC) by telephone but need to meet the requirements for submission of the written report.

HIPAA does not prohibit the electronic transmission of Personal Health Information (PHI). Electronic communications, including email, are permitted, although HIPAA-covered entities must apply reasonable safeguards when transmitting e-PHI to ensure the confidentiality and integrity of data. March 14, 2021, see 45 C.F.R. § 164.530(c). This includes end-to-end encryption. Failure to meet these requirements could result in a heavy fine per violation.

• Vendor Reporting Instructions SIR 5.6.21
• SIR tip sheet revised 1-12-21
• SIR Vendor LTC Reporting Form-Revised (9.24.2021)
• WRC Post Emergency Restraint Report PERR modified V8.12.20
• Report of Suspected Dependent Adult/ Elder Abuse – SOC 341
• Medication Error Report Diagnostic Tool (10.7.2022) *NEW*

• Mandated Reporter Flowchart for Long-Term Facilities
• Guidance for Reporting Incidents Related to COVID-19
• DDS Directive 3-14-22 Tracking COVID-19 Incidence
• New Expanded Reporting Requirements for Special Incidents – 2017 Letter to Service Providers/ Vendors 
• Notice to All APS Mandated Reporters
• Regional Center Responsibilities for Reporting -Welfare and Institutions Code Section 4659.2
• Use of Seclusion and Behavioral Restraints in Facilities – Health and Safety Code 1180 – 1180.6
• Serious Bodily Injury – Welfare and Institutions Code Section 15630.67
• Vendor SIR Reporting Title 17 Regulations
• DDS Risk Management & Mitigation webpage