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Get NY OPWDD 147 2016-2024

Ns the information available at the time of its completion. REPORTING FORM: 14 NYCRR Part 624 - Reportable Incidents and Notable Occurrences 1. AGENCY COMPLETING FORM 2. FACILITY (if applicable) 3. PROGRAM TYPE 4. ADDRESS 5. PHONE 6. MASTER INCIDENT NUMBER 7. AGENCY INCIDENT NUMBER 8. WAS A RELATED INCIDENT PREVIOUSLY REPORTED? 1 YES 2 NO TO BE COMPLETED BY STAFF DESIGNATED IN POLICY 9. NAME OF PERSON(S) RECEIVING SERVICES (Last, First) 10. DATE OF BIRTH 11. GENDER 12. TABS ID (.

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