§300.APPENDIX G. Facility Report

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

 

Facility Name  ___________________________								Phone  ___________________
Address  ______________________________					City  ______________				Zip  __________
Facility-wide occurrence?	Yes		No				Resident Name ______________________________
							Age  ________  M ___  F ___
Were other residents involved?		Yes		No		(Complete this form for each resident unless occurrence is facility wide.)

 

Type of occurrence: 1.   Suspected abuse/neglect 2.   Missing person 3.   Communicable disease 4.   Medication error 5.   Unexplained death 6.   Loss of essential staff

7.   Fire 8.   Bldg. emergency 9.   Loss of essential utilities 10.  Bomb threat 11.  Serious injury 12.  Sexual assault 13.  Other  ________________

Evacuation:   Yes  ____  No ____ # of residents  ____________________ evacuated from   __________________ ________________________________ Expected return  __________________ ________________________________

 

Status of resident:

 

Witness to occurrence:

 

Police Notified? Doctor Notified? Resident sent to hospital? Resident Hospitalized? Family/Guardian Notified?

Yes    No   Yes    No   Yes    No   Yes    No   Yes    No

Comment:   ________________________________________ Comment:   ________________________________________ Comment:   ________________________________________ Date:   _____________  Hospital:  ______________________ Comment:   ________________________________________

 

Complete Description of Occurrence:

 

 

 

 

 

 

 

 

Further description attached?

 

Person completing form: ________________________________        Title:  _____________________________

Form Faxed?   Yes   No                                                Reported by phone?    Yes   No

by whom?  ________________________________             by whom? _________________________________

date:  ______________________  time:  ________              date: ____________________   time:   __________

 

(Source:  Added at 26 Ill. Reg. 3113, effective February 15, 2002)