Shared Information Form

The Shared Information Form is used by a vendor and /or long-term health care facility to report a client occurrence to the Service Coordinator that does not require a Special Incident Report (SIR).  This allows the vendors and/or Long-term care facilities to communicate with ACRC and collaboratively plan for the health and safety of the client.

The Shared Information occurrences should be reported by the vendor or long-term health care facility directly to the assigned Service Coordinator either verbally, email, or using the Shared Information form (whichever is determined most appropriate) within 24 hours of learning of the event.

 Please review the ACRC Shared Information Form Instructions, Vendor Special Incident Reporting Requirements (May 2026), and DDS’ Vendor T17 Guidelines to determine when a Special Incident Report (SIR) or Shared Information Form is required. There are additional supplemental documents related to Special Incidents located on our website under Service Providers/SIR Forms (Special Incident Reporting (SIR) Forms/Documents – Alta California Regional Center). For further clarification please contact Julie Rachfal, SIR Coordinator 916 978-6337.