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Get PA DPW-ARL 2005-2024

Th Initial and Final FACILITY INFORMATION NAME OF LEGAL ENTITY: NAME OF ADMINISTRATOR TELEPHONE: ADDRESS OF LEGAL ENTITY: LICENSE # NAME OF PERSONAL CARE HOME (if different from Legal Entity): COUNTY NAME/#: ADDRESS OF PERSONAL CARE HOME (if different from Legal Entity): DATE/TIME OF INCIDENT Date: AM/PM Time: TYPE OF INCIDENT: Check all that apply: Death of a resident. Physical act by a resident to commit suicide. Serious bodily injury or trauma requiring treatment at a hospital or m.

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