DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62447 Rev. 04/10 STATE OF WISCONSIN DHS 13. Please record all responses given. Entities may use their own forms however any written statement must be attached and submitted with the Misconduct Incident Report DQA form F-62447. 05 3 a Wis. Admin* Code Page 1 of 8 MISCONDUCT INCIDENT REPORT GENERAL INSTRUCTIONS Use this form to report incidents of alleged misconduct client abuse or neglect or misappropriation of client property and injuries of unknown source. The Department reviews this report to determine whether further investigation of the incident is warranted* So that the Department may make this determination please complete the Misconduct Incident Report in its entirety. Use the following information as guidance when completing this form* I. ENTITY INFORMATION Page 3 The entity or facility named is the entity responsible for the care of the affected person* The Department will send all responses regarding the report to ....
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How to fill out the WI DHS F-62447 online
The WI DHS F-62447 form, also known as the Misconduct Incident Report, is essential for documenting incidents of alleged misconduct, neglect, or abuse. This guide will provide you with step-by-step instructions on how to complete this form accurately and efficiently online.
Follow the steps to complete the WI DHS F-62447 form online.
- Click the ‘Get Form’ button to access the Misconduct Incident Report and open it in your preferred editor.
- Begin with the ENTITY INFORMATION section. Enter the name of the entity or facility responsible for the care of the affected person, the Federal Provider Number, and the street address. Include the name of the administrator and the entity type code found in the instructions.
- Move on to the SUMMARY OF INCIDENT section. Clearly state when the incident occurred, providing an exact date and time if known, or an approximate estimate if not. Describe the incident briefly but comprehensively, and explain its impact on the affected person.
- In this section, explain what actions the entity took to protect the affected person from further potential misconduct and indicate the specific location of the incident if applicable.
- Fill out the AFFECTED PERSON INFORMATION. Provide the name, date of birth, address, and contact number of the person affected by the incident. If needed, include information about a parent or legal guardian.
- Next, complete the ACCUSED PERSON INFORMATION section by including the name, social security number, and relevant details of the accused, if known. Be sure to document their current occupational status.
- In the LAW ENFORCEMENT INVOLVEMENT section, check if law enforcement was contacted. If applicable, provide details such as the officer's name and case number.
- Provide information about PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT. This includes names and contact details of individuals who can provide additional information about the incident.
- For the ENTITY'S INVESTIGATIVE RECORDS section, summarize or attach relevant findings from the internal investigation regarding the incident.
- Complete the section regarding the PERSON PREPARING THIS REPORT. Include their name, title, and contact information, and ensure it is signed and dated.
- Utilize the WRITTEN STATEMENT section to collect statements from those involved, ensuring details about the incident are thoroughly documented.
- Finally, review the entire form for accuracy. Once completed, save any changes, download a copy for your records, print it if necessary, or share it as required.
Start filling out your WI DHS F-62447 form online to ensure accurate reporting of incidents.
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