Misconduct Incident Report Page 4
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8F-62447 (Rev. 04/10)
Page 4 of 8
EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further
potential misconduct.
CHECK the specific location where the incident happened.
Another Location – Explain:
At Your Entity
During Transport
III. AFFECTED PERSON INFORMATION
If more than one, include additional pages.
Name – Affected Person
Date of Birth (mm/dd/ccyy)
Sex
Male
Female
Address
Telephone Number
City
State
Zip Code
If the affected person is adjudicated incompetent or under 18, or has an authorized Power of Attorney for Health Care, include the name,
address, and telephone number of parent, guardian, or legal representative.
Name - Parent, Guardian, or Power of Attorney
Telephone Number
Address
City
State
Zip Code
IV. ACCUSED PERSON INFORMATION
If more than one, include additional pages.
Name - Accused Person (if known)
Social Security Number
Position or Title or Relationship to Affected Person (at the time of the incident)
Sex
Date of Birth (mm/dd/ccyy)
Male
Female
List any known credential held by the accused at time of the incident;
Non Credentialed Staff
Resident
e.g., RN, LPN, social worker, security guard, professional counselor.
Credentialed Staff
Other:
Home Street Address
Home Telephone Number
City
State
Zip Code
NOTE: If employer is other than the reporting entity, provide information about accused person’s current employer.
Name – Employer
Sex
Telephone Number
Male
Female
Street Address
City
State
Zip Code
NOTE: If accused person is under 18, provide parent(s) or guardian information.
Name(s) - Parent or Guardian
Sex
Telephone Number
Male
Female
Street Address
City
State
Zip Code
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