Get Nh_self_report . Pdf - Dhmh - Dhmh Maryland

Filling out the Nh_self_report.pdf form is an essential process for reporting incidents in comprehensive and extended care facilities. This guide will provide you with clear, step-by-step instructions to assist you in completing the form online effectively.

Follow the steps to complete the self-report form online

1. Click 'Get Form' button to access the self-report form and open it in your chosen editor.
2. Enter today's date and the time when you are filling out the report. These fields are crucial for documenting the timing of the incident.
3. Fill in the provider name, mailing address, provider number, city, state, zip code, telephone number, extension, fax number, and email address. This information identifies the facility involved.
4. Indicate the person completing the report and provide their direct number, as well as their title or relationship to the resident.
5. List the names of the resident(s) involved in the incident being reported.
6. Select the type of report by checking the relevant box for abuse, neglect, misappropriation of resident property, or injury of unknown origin.
7. Provide the date and time of the incident, as well as the location where the incident occurred.
8. List any witnesses to the incident and, if applicable, include the name and license number of the alleged perpetrator(s).
9. Indicate whether local law enforcement has been contacted by checking 'Yes' or 'No'. If 'Yes', provide the date and time of contact and the case number.
10. Describe the events of the incident in detail in the comments section. This information is critical for the review process.
11. Document any measures taken to prevent similar incidents in the future in the comments field.
12. Summarize the results of the investigation in the comments section. It's important to note that serious bodily harm reports must be forwarded within 2 hours, all other reports within 24 hours, with investigation results forwarded within 5 days.
13. Prepare to submit your report by reviewing all entries for accuracy. After confirming correctness, save your changes, and download, print, or share the completed form as needed.

Complete your self-report form online today to ensure accurate and timely documentation of incidents.