Misconduct Incident Report (Page 3 of 8) in pdf

Misconduct Incident Report Page 3

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Quality Assurance

DHS 13.05(3)(a), Wis. Admin. Code

F-62447 (Rev. 04/10)

Page 3 of 8

MISCONDUCT INCIDENT REPORT

Completion of this form is required by DHS 13.05(3)(a), Wis. Admin. Code. Failure to file a complete and accurate report of an incident of

alleged misconduct, as required, may subject the entity to forfeiture or other sanctions specified by the Department under DHS 13.05(3)(e),

Wis. Admin. Code, and may delay the investigation process. Personal information will be used to investigate the reported incident and the

results of the investigation may be shared with other authorized investigative agencies.

This report form must be completed in its entirety. Additional information may be attached.

TYPE OR PRINT NEATLY IN BLACK INK.

I. ENTITY INFORMATION

Name – Entity or Facility

Telephone Number

Street Address

County

Federal Provider or Certification No.

City

State

Zip Code

State License, Approval, or Registration No.

Name – Administrator

Entity Type Code (See instructions.)

II. SUMMARY OF INCIDENT

Date Discovered

Date Occurred

INDICATE

when the incident occurred. If the exact date and time are

Time Occurred

(mm/dd/ccyy)

unknown, make a reasonable estimate and indicate that the date and time

are estimated. Include the date the incident was discovered, if other than

the date the incident occurred.

BRIEFLY DESCRIBE THE INCIDENT in the space below. Summarize the incident here even if additional documentation is attached.

DESCRIBE THE EFFECT that the incident had on the affected person, the person’s reaction to the incident, and the reaction of others who

witnessed the incident.

Misconduct Incident Report Page 3