Death Serious Report Fax Cover Sheet Minnesota printable pdf download

DEATH OR SERIOUS INJURY REPORT

FAX TRANSMISSION COVER SHEET

DATE: ______________________________ NUMBER OF PAGES: _____

(including this cover sheet)

DESTINATION INFORMATION:

Department of Human Services Licensing Division

PO Box 64242, St. Paul, MN 55164-0242

Phone number: (651) 296-3971

Destination FAX Number: (651) 297-1490

Ombudsman for Mental Health and Developmental Disabilities

121 7

Place East, Suite 420, St. Paul, MN 55101-2117

Phone number: (651) 757-1800 or 1-800-657-3506

Destination FAX Number: (651) 296-1021

SENDER INFORMATION:

Sender: _____________________________________________________________________________________

Program: _________________________________________________ 245B License Number: ______________

Phone Number: ____________________________

FAX Number: ________________________________

245B Service Type (check one; if your program is not licensed to provide one of the services listed do not send the report to

DHS):

____ SILS (Semi-Independent Living Services)

____ WS (Waivered Services)

____ CR (Crisis Respite)

____ DTH (Day Training and Habilitation)

____ SES (Supported Employment Services)

____ RS (Residential Services-ICF/MR)

____ RS-N (Residential Services-SLF only)

INSTRUCTIONS:

ATTACH THE COMPLETED REPORT TO THIS FAX COVER SHEET

The Ombudsman offers editable Death and Serious Injury Report reporting forms that may be completed on line,

printed and faxed.

Serious Injury

Death

FAX or MAIL the death or serious injury report both to the DHS Division of Licensing and to the Ombudsman. If

mailed, a phone call must be made within 24 hours of the death or serious injury to the Ombudsman to meet the

mandatory reporting requirements.

Death or serious injury of persons with developmental disabilities served in programs licensed by DHS under

Minnesota Statutes, chapter 245B, must be reported within 24 hours to both the Ombudsman and the DHS Licensing

Division for services licensed under MS §245B.

PRIVACY NOTICE

This fax message may contain private or confidential data.

The information contained in this facsimile message is intended for the use of the addressee listed below. This

information may be protected by state and federal privacy regulations. If you are not the intended recipient or the person

responsible for delivering this information to the intended recipient, you are hereby notified that any disclosure, copying,

or distribution of this information is strictly prohibited. If you have received this fax in error, please notify the sender

immediately by telephone.

11.17.2008

Death Serious Report Fax Cover Sheet Minnesota

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