Follow the steps to fill out the OR DHS APD 2803 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today’s date and time when the report is being filled out. Make sure to note whether the time is a.m. or p.m.
3. Fill in the complete facility name, address, city, ZIP code, and phone number.
4. Provide the name, title, and email of the person reporting the incident from the facility.
5. Document the incident details: the date and time of the incident (including a.m. or p.m.), the incident location, and the name of the person who reported the incident to facility administration along with their staff title or relationship to the resident.
6. List all residents involved in the incident. For each resident, include their name, whether they have Medicaid, their date of birth, their gender, and any relevant diagnosis.
7. Describe the incident in detail, including any injury or adverse effects to the resident(s). Indicate if the situation is ongoing and provide a description if applicable.
8. Specify if anyone witnessed the incident. If yes, provide the witness's name, phone number, and their staff title or relationship to the resident.
9. For each reported perpetrator, document their name, phone number, staff title or relationship to the resident, and their license or certificate number. Indicate if they are on administrative leave.
10. Answer all relevant questions regarding immediate measures taken to protect the resident(s), the resident's current status at the facility, if similar incidents have occurred before, and whether a crime is also being reported.
11. List additional comments as necessary and provide the name and title of the person completing the report, along with their signature and date.
12. Before submitting, ensure to save the form. Then, click the submit button to send the completed form to the designated email for reporting incidents.

Complete your forms online effectively to ensure compliance and timely reporting.