Get Mi Dhhs Cwl-4603 2015-2025

Filling out the MI DHHS CWL-4603 form online can be a straightforward process when you have clear guidance. This guide will provide step-by-step instructions to ensure that you complete each section of the form accurately and efficiently.

Follow the steps to complete your MI DHHS CWL-4603 form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Identify the facility information section. Enter the license number of the facility, along with the name, address, and phone number of the facility or home. Ensure all information is accurate and up-to-date.
3. Complete the section detailing the persons in care involved in the incident. For each person, fill in their name, age, sex, and home address if different from the facility's address. Include contact information when applicable.
4. If there are other individuals involved or witnesses, complete their details in the respective section. Provide their names, addresses, and phone numbers as required.
5. Fill out the notification details. Indicate who was notified about the incident, the notification date, and the corresponding agency or person (e.g., physician, law enforcement agency). Ensure to provide accurate times of notification as well.
6. Describe the incident, accident, illness, death, or fire in detail. Include the date, time, the nature of the incident, location, and any relevant circumstances that contributed to the situation.
7. If applicable, indicate if first aid was given and by whom. Record any diagnoses, including the name of the treating physician, medical facility, or hospital involved, with their contact information.
8. Finish the form by providing the signatures of both the person completing the report and the licensee or responsible person, including their titles and dates.
9. Upon completing the form, save your changes. You can then download, print, or share the form as needed before submitting it to your licensing consultant.

Complete your MI DHHS CWL-4603 form online today and ensure your documentation is accurate and complete.