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North Carolina Department of Health Human Services Division of Health Service Regulation Psychiatric Hospital Death Report Form This form is used to report deaths for state facilities operating in accordance with North Carolina G.S. 122C Article 4 Part 5 psychiatric hospitals licensed under G.S. 122C and inpatient psychiatric units licensed under G.S. 131E. All deaths related to use of seclusion or restraint accidents homicides suicides or violence must be reported. Please provide an explanation for any requested information that is unavailable. If additional space is needed attach separate sheets referencing the part of the form to which the information pertains. Additional information that is considered relevant such as client assessments and discharge summaries may be included* Please keep a copy of the report for your records. Mail or fax form to Complaint Intake Unit 2711 Mail Service Center Raleigh NC 27699-2711. Fax 919-715-7724. Phone 800-624-3004 Section 1 Reporting Facility Address Name of reporting facility Medicare/Medicaid Provider if applicable County License if applicable Facility Director Telephone First Person to Discover Decedent Staff first receiving report of decedent s death Person/Title Preparing Report Date/Time Report Prepared Section 2 Client Information Unit/Ward if applicable Date of Birth Age Adjudicated incompetent Yes No Weight if known Race Date s of last two 2 medical exams if known Admitting Diagnoses Client Record Name of Decedent Sex Date of most recent admission to a State operated psychiatric developmental disability or substance abuse facility if known illness if known Primary/secondary mental illness developmental disability or substance abuse diagnosis DHHS / DHSR 4700 rev 11-2007 Page 1 of 2 Section 3 Circumstances of Death Place where decedent died Date and time death was discovered Physical location decedent was found Cause of death if known Was decedent restrained at the time of death or within 7 days of death Was decedent in seclusion at the time of death or within 7 days of death Describe events surrounding the death Section 4 Other Information Please list other authorities such as law enforcement or the County Department of Social Services that have been notified have investigated or are in the process of investigating the death or events related to the death. If additional space is needed attach separate sheets referencing the part of the form to which the information pertains. Additional information that is considered relevant such as client assessments and discharge summaries may be included* Please keep a copy of the report for your records. Additional information that is considered relevant such as client assessments and discharge summaries may be included* Please keep a copy of the report for your records. Mail or fax form to Complaint Intake Unit 2711 Mail Service Center Raleigh NC 27699-2711. Fax 919-715-7724. Mail or fax form to Complaint Intake Unit 2711 Mail Service Center Raleigh NC 27699-2711. Fax 919-715-7724. Phone 800-624-3004 Section 1 Reporting Facility Address Name of reporting facility Medicare/Medicaid Provider if applicable County License if applicable Facility Director Telephone First Person to Discover Decedent Staff first receiving report of decedent s death Person/Title Preparing Report Date/Time Report Prepared Section 2 Client Information Unit/Ward if applicable Date of Birth Age Adjudicated incompetent Yes No Weight if known Race Date s of last two 2 medical exams if known Admitting Diagnoses Client Record Name of Decedent Sex Date of most recent admission to a State operated psychiatric developmental disability or substance abuse facility if known illness if known Primary/secondary mental illness developmental disability or substance abuse diagnosis DHHS / DHSR 4700 rev 11-2007 Page 1 of 2 Section 3 Circumstances of Death Place where decedent died Date and time death was discovered Physical location decedent was found Cause of death if known Was decedent restrained at the time of death or within 7 days of death Was decedent in seclusion at the time of death or within 7 days of death Describe events surrounding the death Section 4 Other Information Please list other authorities such as law enforcement or the County Department of Social Services that have been notified have investigated or are in the process of investigating the death or events related to the death.