Get State Of Mn Fillable Serious Injury Report Form

This guide provides clear instructions on how to effectively complete the State Of Mn Fillable Serious Injury Report Form online. Following these steps will ensure a smooth and accurate submission.

Follow the steps to fill out the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the county and the date on which the report is being made at the top of the form.
3. In the 'Client Information' section, provide the last name, first name, middle initial, street address, city, state, zip code, telephone number, ethnic background, guardianship status, legal status, gender, and client date of birth.
4. Indicate if the client is currently receiving services by marking the appropriate checkboxes available in this section.
5. Next, move to 'Reporter Information.' Provide the reporter’s last name, first name, title, telephone number, fax number, agency or program name, and street address. Be sure to answer 'Yes' or 'No' regarding the client's eligibility for Medical Assistance.
6. In the 'Injury Information' section, enter the date and time of injury if known. Choose the type of injury from the provided options.
7. Specify the incident type by selecting from the choices provided, and describe how the injury occurred in the designated area.
8. Indicate the name of the provider or corporation where the injury occurred.
9. Fill out the diagnosis information including Axis I, II, and III, and list any current medications the client is taking.
10. Identify any other agencies involved, referring to the list provided.
11. Finally, review all entered information for accuracy before saving changes. Once completed, you can download, print, or share the form as needed.

Complete the Serious Injury Report Form online today to ensure timely processing.