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Get NC DHSR/HCPR 4501 2014-2024

DHSR/HCPR Form No. 4501 Rev. 06/24/2014 Additional information available at www. ncnar. org Print Name and Title of Person Preparing Report Signature of Person Preparing Report Date Signed. Health Care Personnel Registry N*C. Department of Health Human Services FAX 919 733-3207 Phone 919 855-3968 24-HOUR INITIAL REPORT Division of Health Service Regulation 2719 Mail Service Center Raleigh NC 27699-2719 Allegation Report by Facility/Provider All allegations against health care personnel including injuries of unknown source which appear to be related to resident abuse or neglect must be reported to the HCPR within 24-hours. see NC Gen* Stat. 131E-256 g Provider Information Certain providers must report a reasonable suspicion of a crime with resulting serious bodily injury within 2-hours and a reasonable suspicion of a crime without resulting serious bodily injury within 24-hours. see 42 U*S*C. 1320b-25 Facility/ Provider Type County Facility/Provider Name National Provider r License Main Office Phone Secure Fax Other ID Administrator/ Director Email Address Contact Person Mr. Ms. Title MAIN OFFICE Mailing Address ACTUAL INCIDENT Location Address Allegation/Incident Type City State Zip REASONABLE SUSPICION OF A CRIME under Allegation/Incident Details below Explain check all that apply Is reasonable suspicion of a crime related to any allegation checked below Yes No RESIDENT ABUSE DIVERSION OF FACILITY DRUGS MISAPPROPRIATION OF FACILITY PROPERTY RESIDENT NEGLECT FRAUD AGAINST RESIDENT DIVERSION OF RESIDENT DRUGS FRAUD AGAINST FACILITY INJURY OF UNKNOWN SOURCE Allegation Description Incident Date Time a*m* p*m* Resident Resident Information Full Name Date of Birth Resident s Type of Care/ Service Setting Examples - Home Care Nursing Home Hospital/Acute Care Day Program CAP CBS Substance Abuse Respite etc* Accused Individual Information Hire Job Title Social Security required Last Known Address Home Phone Date of Birth Taxpayer ID or Other Phone Is there a Reasonable Suspicion of a Crime Law Enforcement Incident reported to law enforcement Cell phone work etc* Is there Serious Bodily Injury Reported Date reported Name of law enforcement agency Investigating Officer INVESTIGATION REPORT MUST FOLLOW WITHIN 5 WORKING DAYS The results of all investigations must be reported within five working days of the initial notification to the department. see NC Gen* Stat. 131E-256. g Failure to comply may result in a report to the agency having jurisdiction for compliance enforcement. Health Care Personnel Registry N*C. Department of Health Human Services FAX 919 733-3207 Phone 919 855-3968 24-HOUR INITIAL REPORT Division of Health Service Regulation 2719 Mail Service Center Raleigh NC 27699-2719 Allegation Report by Facility/Provider All allegations against health care personnel including injuries of unknown source which appear to be related to resident abuse or neglect must be reported to the HCPR within 24-hours. see NC Gen* Stat. 131E-256 g Provider Information Certain providers must report a reasonable suspicion of a crime with resulting serious bodily injury within 2-hours and a reasonable suspicion of a crime without resulting serious bodily injury within 24-hours. .

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