Date Received: Date Reviewed: Initials: Action: No Follow-Up Needed Phone Call Follow-Up SI Opened AFC LICENSING DIVISION - INCIDENT / ACCIDENT REPORT Michigan Department of Human Services Name of.
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How to use or fill out the BCAL-4607-Fillable online
The BCAL-4607-Fillable is a crucial document for reporting incidents and accidents in facilities regulated by the Michigan Department of Human Services. This guide provides clear, step-by-step instructions to help users complete the form efficiently and accurately.
Follow the steps to successfully complete the BCAL-4607-Fillable online.
- Click the ‘Get Form’ button to access the document and open it in your online editor.
- Fill in the date received and date reviewed at the top of the form to track the submission timeline.
- Select the appropriate action taken by checking one of the options for follow-up. Choose 'No Follow-Up Needed,' 'Phone Call Follow-Up,' or 'SI Opened.'
- Provide information about the facility or home by entering the name, license number, address, and contact details.
- Identify the person directly involved in the incident by entering their name and selecting their role as a resident, employee, or visitor.
- If there are other individuals involved or witnesses, include their names and select their corresponding roles.
- Detail the facts of the incident, including the date, time, location, and a description of what occurred. Be thorough in explaining any injuries.
- Record any actions taken by staff and treatment provided. Attach additional sheets if necessary.
- Outline any corrective measures taken to prevent future incidents, also attaching supplementary pages if needed.
- Provide information about the treating physician or medical facility, including contact details and the date and time care was given.
- List all persons notified regarding the incident, including agencies, their notification dates, and whether written notice was provided.
- Sign the report in the designated signatures section. Include the print name, title, and date of the person completing the report, as well as the licensee or administrator's signature.
- Once completed, save your changes, and consider downloading, printing, or sharing the form as needed.
Complete the BCAL-4607-Fillable and ensure proper documentation of incidents online today.
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