Get Self Report Letter Working Form

Filling out the Self Report Letter Working Form online is essential for home and community support services agencies to report allegations of abuse, neglect, and exploitation. This guide provides clear instructions on how to complete the form, ensuring compliance with regulatory requirements while maintaining clarity and support throughout the process.

Follow the steps to successfully complete the Self Report Letter Working Form online.

1. Click the ‘Get Form’ button to obtain the Self Report Letter Working Form and open it in your preferred online document editor.
2. Begin by entering your full name and title in the designated fields to identify the reporting person.
3. Provide the name, address, telephone number, and license number of your agency in the appropriate sections.
4. Input the name of the individual who reported the allegation, as well as the date and time your agency first became aware of the alleged reportable conduct.
5. Fill in detailed information regarding the patient or client involved, including their name, date of birth, social security number, and payment source.
6. Describe the services provided, detailing the type and number of hours worked.
7. Include the patient/client's medical history, diagnoses, cognitive status, and any functional assistance needed to fully understand their circumstances.
8. Document the date, time, and location of the alleged reportable conduct clearly and precisely.
9. Indicate the type of reportable conduct (abuse, neglect, or exploitation) and provide a narrative detail with specifics of the allegation.
10. Record the name and contact information of the alleged perpetrator and list any witnesses or others who may have relevant information.
11. Note any injuries or adverse effects experienced by the patient/client, as well as assessments made, required treatments, and preliminary actions taken.
12. Detail the immediate actions your agency has taken to ensure the health and safety of the patient or client and to prevent recurrence.
13. Verify that the incident was reported to the Department of Family and Protective Services before submitting this form.
14. Once all fields are completed accurately, save your changes, and choose to download, print, or share the form as required.

Complete your Self Report Letter Working Form online today to ensure compliance and safeguard those in your care.