Reportable Form

Facility Name:   

Facility Address:  

Telephone:   Bed Capacity: CCNH: RHNS: CCNH/RHNS:  

Date of report_________________________ Report Number:    Classification:  A   B  C  D  E 

Is this a “Follow up” to previously submitted form?   Yes No (If Yes -  Attach Original Report )    

Patient Information 

Name:  Age:  

Date of Admission:                                                                                       Room #______________________ 

Current Diagnoses:____________________________________________________________________________________________  

Date of Event:    Time of Event: AM   PM Location of event:   

Nature and Description of Event:  

Injury, Distress and/or Discomfort (if any):                                

Full Name of Witness(es):   

Name of Physician Notified:____________________________________________   Date/Time of Notification:__________________  

Physical Exam:  Yes No   Physician Report Findings/Orders/Treatment:  

Disposition/Comments/Actions Taken:  

Family Notification: Yes No          Police Notification: Yes No    Investigation Initiated:  Yes No    

For Class A, B or C, Date and Time DPH was notified by Telephone:  

Signature of Person Filing Report: Date:  

Signature of Administrator: Date:  

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• Guidelines for Reporting and Investigating Significant Events, CMS