Ksbha form 2025

1. Click ‘Get Form’ to open the ksbha form in the editor.
2. Begin by filling in the 'Reporting Facility' section. Enter the name of the facility where the incident occurred.
3. Next, input the 'Date' of reporting and your details under 'Reporting Person', including your name, title, and telephone number.
4. Complete the 'Address' field with your street address, city, state, and zip code.
5. Fill in the 'Date of Incident' and 'Date of Birth' fields accurately.
6. Provide patient details by entering their 'Name' and last four digits of their 'SSN'.
7. Document the 'Medical Record No.' (last 4 only) and specify the 'Location of Incident'.
8. Identify the 'Licensee Involved' by including their name and license number. Use a separate form for each licensee if necessary.
9. In the 'Description of Incident', provide a detailed account of what transpired.
10. Outline any actions taken in the 'Description of Sanction, Corrective or Disciplinary Action' section.
11. Indicate whether the internal review process has been completed.
12. If there are additional records relevant to this incident, mention them here. You can use additional pages if needed.

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