Misconduct Incident Report (Page 7 of 8) in pdf

Misconduct Incident Report Page 7

F-62447 (Rev. 04/10)

Page 7 of 8

IX. WRITTEN STATEMENT

Use this page to collect written statements from the accused person, affected person, and witnesses regarding incidents of alleged

misconduct (abuse or neglect or misappropriation of property). Make additional copies of this page as necessary. Completion of this form is

voluntary. It is suggested that entities ask the questions on the following page to obtain additional information and detail about reported

incidents. Please record all responses given. Entities may use their own forms; however, any written statement must be attached and

submitted with the Misconduct Incident Report (DQA form F-62447).

Section 1 - To be completed by Entity

Brief Description of Alleged Incident (e.g., “Marion R’s broken arm,” “the theft of Marion R’s credit card,” “Marion R’s fall.”)

Section 2 - To be completed by Accused Person, Affected Person, or Witness

Full Name (Last, First, Middle Initial)

Home Telephone Number

Street Address

Work Telephone Number

City

State

Zip Code

Position or Title or Relationship to the Affected Person

Section 3 - To be completed by Accused Person, Affected Person, or Witness

Provide as much information as you know about the incident described above. Tell what you know about the incident in detail. Use

additional pages, as needed.

Check if additional pages are included.

SIGNATURE –

Date Signed

Accused Person, Affected Person, or Witness

Misconduct Incident Report Page 7