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

Michigan.gov Home	MDCH Home \| Online Services \| Sitemap \| Contact MDCH

Health Systems & Health Profession Licensing


>	Contact Us

>	Health Professions Programs

>	Licensing for Health Care Professionals

>	Online Lookups

>	Medical Marihuana Program

>	Links

>	Pain & Symptom Management

>	Patient Safety

>	Publications

>	Who We Are

>	Radiation Safety

>	Complaints

>	Health Care Facilities and Programs

>	Health Facility Construction

>	Forms

	Health Systems

	Health Professions

Birth, Death, Marriage and Divorce Records

Physical Health & Prevention

Pregnant Women, Children & Families

Mental Health & Substance Abuse

Health Care Coverage

Statistics and Reports

Providers

Inside Community Health

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):