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- Click ‘Get Form’ to open the Five-Day Follow-Up Report in the editor.
- Begin by circling the type of reportable incident: 'Injury of Unknown Source' or 'Alleged Abuse'.
- Fill in the date, facility name, address, and phone number at the top of the form.
- Enter the resident’s name, date of birth (DOB), room number, and whether they are certified bed (yes/no).
- Specify the type of injury or alleged abuse by checking appropriate boxes for physical, verbal, sexual, mental neglect, or misappropriation.
- Document details such as the name of the alleged perpetrator, date/time of the incident, and any relevant diagnoses/medications.
- Provide information on witnesses and describe the characteristics of any injuries observed.
- Summarize interventions in place prior to and following the incident and include a signature/title of reporter at the end.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2005 | 4.8 Satisfied (295 Votes) |
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