Follow the steps to complete your report effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the appropriate agency receiving your report by checking one of the boxes provided at the top of the form. Ensure you choose the correct agency to facilitate proper processing.
3. Indicate whether you are submitting the report as an individual or on behalf of a facility. Complete the corresponding fields for contact information, which include name, telephone, address, and email address.
4. If you are submitting a facility report, provide the facility name and the CCN, which is the CMS certification number. If your facility does not have a CMS certification, enter the state ID number or KDHE facility number.
5. Specify the type of facility by selecting the correct box, whether it is a hospital, psychiatric hospital, ambulatory surgical center, or other.
6. Fill in the name and contact details of the risk manager or contact person, including their telephone number and email address. Ensure all data is accurate.
7. Document the incident identification by entering the incident report number assigned by the facility if applicable. Provide the date of the incident, medical record number, patient name, patient date of birth, and the specific location of the incident.
8. List any licensees involved in the incident, ensuring that separate forms are submitted for each licensee if necessary. Include their name, licensee number, and the last four digits of their SSN, if known.
9. Provide a detailed description of the incident. You may attach a separate sheet if needed to ensure clarity.
10. Describe any corrective actions, education, or disciplinary measures taken regarding the incident. This may also require an additional sheet.
11. Indicate any additional records related to the incident, such as treatment records or external consultant reports.
12. Select the type of incident from the provided list by checking one or more relevant boxes.
13. Conclude by signing the form. The signature must be from the individual or risk manager submitting the report to confirm the information is accurate and complete.
14. After completing the form, you can save changes, download, print, or share the report as needed.

Complete your Risk Management Report Form online today to ensure proper reporting and compliance.