LARA - Facility Incident Report-24 Hours (BHS-OPS-362) Online Submission

LARA: Michigan Department of Licensing and Regulatory Affairs

Michigan.gov: Official Web Site for the State of Michigan

LARA Home | Sitemap | Contacts | Online Services | Press Releases


>	Commercial Services

>	Construction Codes

>	Fire Services

>	Liquor Control Commission

>	Public Service Commission

>	Office of Financial and Insurance Regulation

>	Health Professions

>	Health Systems & Facilities

	Health Systems Forms

	Publications

	Radiation Safety

	Health Care Facilities and Programs

	Nursing Homes and LTC Units

	Health Facility Construction

All About LARA

Agencies, Bureaus & Commissions

Employment, Security & Workplace Safety

Michigan Administrative Hearing System

Office of Regulatory Reinvention

Printer Friendly Text Only Version

Text Version

Share this link:

Facility Incident Report-24 Hours (BHS-OPS-362) Online Submission

DIRECTIONS FOR SUBMISSION OF REPORT
Providers who immediately submit this online form to report abuse or alleged abuse are NO LONGER REQUIRED TO ALSO REPORT TO THE DEPARTMENT BY TELEPHONE as of December 7, 2005. The Facility Investigation Report - 5 Working Days (BHS-OPS-363) form must still be submitted within five (state) working days of the incident.

--Use the "Tab" key or cursor to move through the fields.
**CAUTION: Using the "Enter" key instead of "Tab" will send the form before it is completed.
--Press the "Restart" at the bottom of the form to clear and begin again.
--Print a facility copy of the report by pressing "CTRL" + "p" together and then "Print" BEFORE PRESSING THE "SUBMIT" BUTTON. (this is the only way to retain a copy of the content being submitted.)
--Press "Submit" at the bottom of the form to send the report.
--A "Sent" confirmation page will immediately come up when the "Submit" button is pushed and may be printed for the facility file.

FACILITY INFORMATION

Has this been reported to the Complaint Hotline?Yes No

Date reported to hotline:

Time reported to hotline AM PM

Facility Name:

Street, City, Zip Code:

Administrator/Contact Name:

Daytime Telephone Number:

RESIDENT INFORMATION (if resident(s) involved) If this was a resident-to-resident altercation, please complete information for Resident No. 2 as well.

RESIDENT No. 1:

Resident's Name (No. 1):

Date Of Birth for Resident No. 1 (Mo/Day/Yr):

Last Known Address for Resident No. 1 (Including Room Number):

Daytime Telephone Number for Resident No. 1:

Diagnosis for Resident for Resident No. 1:

Was Resident No. 1 Verbally Abused, Injured, Suffered Pain Or Affected By The Incident?
This includes hitting, slapping, pinching or kicking regardless of the resident's ability to feel
or perceive pain.) YES NO

If Yes, What Was Resident No. 1's Injury?

Is Resident No. 1 Able To Give A Statement? Yes No

What Is Resident No. 1's Current Status?

RESIDENT 2:

Resident's Name (No. 2):

Date Of Birth For Resident No. 2 (Mo/Day/Yr):

Last Known Address for Resident No. 2 (Including Room Number) :

Daytime Telephone Number For Resident No. 2:

Diagnosis For Resident No. 2:

Was Resident No. 2 Verbally Abused, Injured, Suffered Pain Or Affected By The Incident? This includes hitting, slapping, pinching or kicking regardless of the resident's ability to feel
or perceive pain.) YES NO

If Yes, What Was Resident No. 2's Injury?

Is Resident No. 2 Able To Give A Statement?YES NO

What Is Resident No. 2's Current Status?

SUMMARY OF INCIDENT

Date Incident Occurred:

Time Incident Occurred: AM PM

Date Incident Discovered or Reported:

Time Incident Discovered or Reported: AM PM

Please describe what occurred including the location of incident, names and titles
of involved staff and witnesses and information about alleged perpetrator(s) if applicable:

This Report Prepared by:

Date Submitted (Today):

* Spam Block: (What's this?) Add seven plus nine and type the answer here: