Form Dhsr/ac 4207 - Resident Register (Page 4 of 4) in pdf

DHSR/AC 4207 (Rev. 09/11) NCDHHS



Declaration of Residents’ Rights;



Home’s grievance procedures for residents to present complaints and make suggestions as to the home’s

policies and services; and



Home’s willingness to comply with Title VI of Civil Rights Act.

Other:_________________________________________________________________________________________

______________________________________________________________________________________________

Signature______________________________________

F. SIGNATURES

The resident or his/her responsible person should be asked to sign this form only after Sections A-E have been

completed. The administrator or supervisor-in-charge/administrator-in-charge is to review this form with the resident

or his/her responsible person at least once a year and revise it as needed using Section H. Section G is to be

completed at the time the resident is discharged or transfers from the facility.

(Resident or Resident’s Responsible Person)

(Date)

(Administrator or Supervisor-in-Charge/Administrator-in-Charge)

(Date)

G. DISCHARGE/TRANSFER INFORMATION

1. NOTICE OF DISCHARGE/TRANSFER___________________________________________________________________

(Month)

(Day)

(Year)

2. INITIATED BY:  Administrator

 Other_________________________________________________________

Reason(s)_______________________________________________________________________________________

3. DATE OF DISCHARGE/TRANSFER_____________________________________________________________________

(Month)

(Day)

(Year)

 Own Residence

 Another’s Residence (Name)____________________________________________

To:

 A Facility

 Other_______________________________________________________________

Phone (

)

4. NEW ADDRESS______________________________________________________________________________________

5. COPY OF THE DISCHARGE NOTICE HAS BEEN GIVEN TO THE PERSON IDENTIFIED BY THE RESIDENT IN

 Yes (required)

SECTION A, #12 OF THIS FORM AS REQUIRED BY GENERAL STATUTE 131D-4.8?

I acknowledge the above information to be complete and accurate.

(Resident or Resident’s Responsible Person)

(Date)

(Administrator or Supervisor-in-Charge/Administrator-in-Charge)

(Date)

H. REVIEW/REVISION

The space below may be used to revise the information contained on the form.

Changes

:___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

(Resident or Resident’s Responsible Person)

(Date)

(Administrator or Supervisor-in-Charge/Administrator –in-Charge)

(Date)

Form Dhsr/ac 4207 - Resident Register Page 4

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