Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the name of the facility in the designated field to identify the entity submitting the request.
3. Select the type of facility by marking the appropriate box: ADC, AFH, CBRF, or RCAC.
4. Provide the complete address, including street, city, zip code, and county, to specify the location of the facility.
5. Fill in the license number to confirm that the facility is authorized to operate.
6. Indicate the time period of the request by selecting either 'Permanent' or 'Temporary' and providing the relevant dates in the specified format (MM/dd/yyyy).
7. If applicable, enter the name of the resident who is associated with this request, ensuring accurate identification.
8. Answer the question regarding whether the resident is a Family Care or IRIS member by selecting 'Yes' or 'No.' If 'Yes,' include the name of the case manager.
9. Detail the specific action requested in the designated field to clarify the purpose of the form.
10. Describe the existing situation, including any relevant environmental or behavioral factors impacting the request.
11. List the steps that the facility will implement to ensure the resident's safety, as this information is critical for the review process.
12. If the request involves a restraint device, describe any alternatives that have been attempted, attaching any relevant assessments as needed.
13. Sign and date the form as the person completing it and provide their name and title.
14. Review the completed form for accuracy before submitting it to the appropriate DQA Regional Office address.
15. Finally, save any changes, download, print, or share the form as necessary.

Complete your documentation online to ensure all requests are processed efficiently.