Get Il Dph Sexual Assault Transfer Plan Form 2019-2026

Filling out the IL DPH Sexual Assault Transfer Plan Form is an essential step for hospitals ensuring compliance with regulations regarding the treatment of sexual assault survivors. This guide provides clear, step-by-step instructions to help users accurately complete the form online.

Follow the steps to successfully complete the online form

1. Click the ‘Get Form’ button to obtain the IL DPH Sexual Assault Transfer Plan Form. This action will allow you to access and open the form for editing.
2. Begin by filling in Part A of the form, which includes the name of the transfer hospital, mailing address, contact person's title, email, telephone, and fax numbers for both the program and billing.
3. Indicate the number of adult, adolescent, and pediatric sexual assault survivors transferred in the previous year, as well as your estimate for the upcoming fiscal year.
4. Provide details about the area-wide plan, including the name of the treatment hospital or pediatric healthcare facility and the distance from the transferring hospital.
5. Complete the question regarding the number of treatment hospitals within a 20-mile radius and whether your county's population is below 1,000,000.
6. In Part B, describe the procedures for ensuring privacy and support for survivors, as required by the relevant regulations.
7. Attach a copy of the emergency department treatment record needed under the same regulations.
8. Detail the process ensuring pediatric survivors receive treatment within 90 minutes of arrival at the facility.
9. In Part C, review the Conditions of Approval and confirm understanding by providing the necessary signatures as required.
10. Once all sections are completed, save your changes. You can download, print, or share the completed form as needed.

Complete your documents online to ensure compliance and provide critical support to sexual assault survivors.