Alternative Required Healthcare Facility Event Reporting
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Report Type
Report Type
This form is only to be used for submitting a report of type initial. It will be submitted as an initial report.
Initial
Facility
Facility
Select Your Type:
Please select
ALC
Ambulatory Surgery Center
End Stage Renal Dialysis
FQHC
Home Health
Hospice
Hospital
LTC
Other
Rural Health
Name of Facility:
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Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Name of Facility:
Please select
Email Address(es):
Patient/Resident Information
Patient/Resident Information
First Name:
Last Name:
Date of Birth:
Age:
Cognition Score:
Event Reporting
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:
Please select
Death, other than natural causes
Disaster/fire/loss of utilities
Missing patient/resident
Suspicion/allegation of abuse/neglect
Allegation Type:
Please select
Physical harm/injury
Misappropriation of property/funds
Use of profanity, gestures, acts
Neglect
Fall
Elopement
Other
Please specify:
Suspicion/Allegation of Abuse/Neglect:
Please select
Elopement
Facility personnel
Fall
Family or visitor
Other
Resident to resident/Patient to patient
Please specify:
Victim's First Name:
Victim's Last Name:
Cognition Score:
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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:
Please select
No
Yes
Is this person a CNA?
Please select
No
Yes
Click the button to add more personnel.
Add
Notifications
Notifications
Law Enforcement Notification
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.
Law Enforcement Notified?
Yes
No
Why or why not?
Who:
When:
Case Information:
Department of Human Services (DHS) Notification
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
Health Department Notification
Date Notified:
Time Notified:
Investigation Conclusion
Investigation Conclusion
Conclusionary summary statement of facility investigation (Please include all specific interventions put in place to prevent further occurrences):
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Upload File
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