Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Part A, enter the name of the treatment hospital in the designated field, followed by the mailing address. Provide the contact information for the program, including the contact person's title, email address, telephone number, and fax number.
3. Fill in the contact information for billing, including the billing contact person's name, email, telephone number, and fax number. Next, estimate the number of sexual assault survivors to be served in the upcoming fiscal year.
4. Answer whether there is an area-wide plan with acceptance of transfer for survivors of all ages. If yes, list the names of the hospitals with agreements. Similarly, specify if there is an area-wide plan for pediatric patients and provide necessary details.
5. Indicate whether the emergency department attending physicians and advanced practice registered nurses are qualified medical providers. If not, describe how the hospital meets training requirements for sexual assault response.
6. In Part B, attach a copy of the hospital's sexual assault plan and any appropriate documents distributed to sexual assault survivors, such as information about sexually transmitted diseases, medication, medical procedures, follow-up visits, and emergency contraception.
7. Describe the procedures for evidence collection, counseling resources, and training programs for staff. Attach any related flowcharts or protocols as necessary.
8. In Part C, review and sign the Conditions of Approval. Ensure that the hospital acknowledges its responsibilities concerning emergency services, billing practices, record retention, and reporting procedures.
9. Once all sections are filled out, review the document for completeness, and make any necessary corrections. Users can then save changes, download or print the completed form, or share it as required.

Take the next step in supporting survivors by completing the IL DPH Sexual Assault Treatment Plan Form online today.