Get Or Dhs Apd 2803 2019-2025

Filling out the OR DHS APD 2803 form is an essential process for nursing facilities to report incidents responsibly and in compliance with regulations. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the OR DHS APD 2803 online

1. Click the ‘Get Form’ button to access the OR DHS APD 2803 form and open it for editing.
2. Begin by filling in the section titled 'What alleged violation are you reporting.' You should check all that apply, such as mistreatment, abuse, or neglect.
3. Next, indicate whether the alleged violation resulted in serious bodily injury by selecting 'Yes' or 'No'.
4. Provide the facility information, including today’s date, time, facility's complete name, CCN number, address, city, state, ZIP code, and phone number.
5. Complete the section for the name of the person reporting the incident, including their last name, first name, title, and email.
6. In the incident details section, fill out the incident date, time, and location. If the date or time is unknown, specify that accordingly.
7. Describe the incident in detail, including any immediate measures taken to prevent recurrence. This section is crucial and must be thoroughly completed.
8. Identify any witnesses to the incident. Provide their names, contact details, and their relationship to the resident involved.
9. List all residents involved in the incident. For each resident, include their first and last name, Medicaid status, gender, date of birth, Medicaid number if applicable, relevant diagnosis, and any outcomes related to the incident.
10. If applicable, fill out the reported perpetrators section, providing names and titles for up to two reported perpetrators.
11. Answer the questions regarding whether the incident is a crime and if law enforcement has been notified, including pertinent details.
12. Complete the final section with the name of the person completing the form, their title, and date.
13. Once the form is completed, click the ‘SUBMIT’ button to attach the form to an email ready for secure submission.
14. If you cannot use the 'Submit' button, ensure the completed form is emailed or faxed to the appropriate complaint unit.

Start completing your OR DHS APD 2803 form online today to ensure that incidents are reported promptly and effectively.