Alternative Required Healthcare Facility Event Reporting

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Report Type


This form is intended to be used as an initial report by a healthcare facility staff member who has no facility login to the online event reporting page. This form is not intended for use by the public.
Initial

Facility

Select Your Type:

Name of Facility:

Patient/Resident Information

Event Reporting


Name of Person Completing Report:
Credentials of Person Completing Report:
Facility Contact Person:
Date of Event:	Time of Event:
Type of Event Being Reported:
Allegation Type:
Please specify:
Suspicion/Allegation of Abuse/Neglect:
Please specify:
Victim's First Name:	Victim's Last Name:	Cognition Score:
Click below to add more information.


Is the individual capable of providing an explanation of the event or capable of participating in investigation?	Yes	No

Provide a brief explanation of event being reported. Please include name(s) of Patient/Resident/Personnel/Family/Visitors involved with event:


Allegation involved facility personnel?	Yes	No


For each PERSONNEL involved, please provide the following information:
Full Name:	Job Title:	Social Security #:
License/Certification #:	Date of Birth:	Date of Hire:
Last Known Address, City, State, Zip;		Phone #:
If terminated, date of termination:	Previous Disciplinary Actions:	Is this person a CNA?

Notifications

Law Enforcement Notification


Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.

Department of Human Services (DHS) Notification


Notify Dakota At Home (1-833-663-9673) only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.


DHS (not the Ombudsman)? APS worker notified?	Yes	No
Why or why not?
Who was notified and when?

Health Department Notification

Investigation Conclusion

Conclusionary summary statement of facility investigation (Please include all specific interventions put in place to prevent further occurrences):

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