Service Provider Forms Forms/Documents


The sections below offer forms frequently used by Alta California Regional Center (ACRC) service providers. 


Post-Emergency Restraint Report Forms

It is necessary for ACRC to evaluate the appropriate use of emergency intervention procedures including restraint. Service providers shall submit the Post Restraint Reporting form along with the SIR they submit for a restraint. Questions regarding this can be directed to Julie Rachfal, SIR Coordinator or (916) 978-6337.

Post-Emergency Restraint Report Form-SIR - ARM Level
Post-Emergency Restraint Report Form-SIR - CCH/EBSH


Special Incident Reporting (SIR) Forms/Documents

Service providers have the responsibility to report incidents 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. Please refer to Title 17, Section 54327 for reporting requirements. Below are forms and SIR resources to assist service providers with meeting the mandate.


Special Incident Report

Instructions for Completing ACRC SIR Form

Shared Information Reporting

Death Report


Residential Provider Forms

When it comes to documentation, providers of residential services must comply with ACRC Vendor Agreements and Title 17 Regulations. Service providers must have a Client file for each resident, a Personnel file for each employee and a Residential Facility file for the home itself.