"Required Self Reports to the Department Form - Drug Abuse and Treatment and Education Programs and Narcotic Treatment Programs" - Georgia (United States)

This fillable "Required Self Reports to the Department Form - Drug Abuse and Treatment and Education Programs and Narcotic Treatment Programs" is a document issued by the Georgia Department of Community Health specifically for Georgia residents.

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Download "Required Self Reports to the Department Form - Drug Abuse and Treatment and Education Programs and Narcotic Treatment Programs" - Georgia (United States)

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GEORGIA DEPARTMENT OF COMMUNITY HEALTH
Healthcare Facility Regulation Division
2 Peachtree Street, NW, Suite 31.250
Atlanta, GA 30303
Tel: 404-657-5550 Fax: 404-657-8934
DRUG ABUSE AND TREATMENT AND EDUCATION PROGRAMS
AND
NARCOTIC TREATMENT PROGRAMS
REQUIRED SELF REPORTS TO THE DEPARTMENT FORM
FACILITY INFORMATION
Facility
Name:__________________________________________________________________________________________
_
License #:_______________________ Address:________________________________________________________
City:___________________________ State:_____________________________ Zip Code:_____________________
Person Reporting Incident:_________________________________ Title:____________________________________
Phone Number:____________________ Fax #:_________________E-mail Address:___________________________
INCIDENT REPORTING INFORMATION (report within 24 hours)
Date:_______________ Time ________________ a.m. / p.m. Incident Occurred
Date:_______________ Time ________________ a.m. / p.m. Facility was aware that reportable incident may have
Occurred
Patient Name: _____________________________ Age:____________ Sex:_____ Date of Birth:__________________
TYPE OF INCIDENT: Please check appropriate box
[ ] Death
[ ] Accident or injury requiring medical treatment and/or hospitalization
[ ] Emergency safety intervention resulting in injury of patient requiring medical treatment beyond first aid
[ ] Incident that resulted in any federal, state, or private legal action by or against the facility which affects any child or
the conduct of the facility.
Briefly describe circumstances of the incident: (attach additional sheet if necessary)
GEORGIA DEPARTMENT OF COMMUNITY HEALTH
Healthcare Facility Regulation Division
2 Peachtree Street, NW, Suite 31.250
Atlanta, GA 30303
Tel: 404-657-5550 Fax: 404-657-8934
DRUG ABUSE AND TREATMENT AND EDUCATION PROGRAMS
AND
NARCOTIC TREATMENT PROGRAMS
REQUIRED SELF REPORTS TO THE DEPARTMENT FORM
FACILITY INFORMATION
Facility
Name:__________________________________________________________________________________________
_
License #:_______________________ Address:________________________________________________________
City:___________________________ State:_____________________________ Zip Code:_____________________
Person Reporting Incident:_________________________________ Title:____________________________________
Phone Number:____________________ Fax #:_________________E-mail Address:___________________________
INCIDENT REPORTING INFORMATION (report within 24 hours)
Date:_______________ Time ________________ a.m. / p.m. Incident Occurred
Date:_______________ Time ________________ a.m. / p.m. Facility was aware that reportable incident may have
Occurred
Patient Name: _____________________________ Age:____________ Sex:_____ Date of Birth:__________________
TYPE OF INCIDENT: Please check appropriate box
[ ] Death
[ ] Accident or injury requiring medical treatment and/or hospitalization
[ ] Emergency safety intervention resulting in injury of patient requiring medical treatment beyond first aid
[ ] Incident that resulted in any federal, state, or private legal action by or against the facility which affects any child or
the conduct of the facility.
Briefly describe circumstances of the incident: (attach additional sheet if necessary)
Immediate Corrective or Safety/Prevention Action Taken:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Names of staff/patients involved or witnesses:
________________________________________________________________________________________________
________________________________________________________________________________________________
List of other persons/agencies notified of accident:
________________________________________________________________________________________________
________________________________________________________________________________________________
Acknowledgement of Information Reported:
I swear that the information reported within this form is true and accurate and completed to the best of my knowledge.
Signature of Person Completing Form:____________________________Title:________________________________
Print Name:____________________________________ Date Completed:____________________________________
For Department Use Only
Date Received:___________________
Date Reviewed:___________________
Reviewed By:____________________
Incident Report #__________________
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