Nevada self report form pdf 2025

1. Click ‘Get Form’ to open the Nevada Self Report Form in our editor.
2. Begin by entering the facility name and address in the designated fields at the top of the form. Ensure all information is typed clearly for accuracy.
3. Next, provide the contact person's details, including their phone number and email address. This is crucial for follow-up communication.
4. Indicate when the alleged incident occurred by filling in the date and time. Specify if it was AM or PM.
5. List all residents involved in the incident, including their names, dates of birth, admission dates, and room numbers. Attach a resident face sheet as required.
6. If applicable, document any staff members involved by providing their names and license numbers.
7. Select the type of report (Initial, Final, or Additional Information) and specify the type of alleged incident from the provided options.
8. Provide a brief description of the event. Attach any relevant medical records or documentation as needed.
9. Complete additional sections regarding emergency room visits, substantiation of allegations against staff, and actions taken to prevent future occurrences.
10. Finally, review all entries for completeness before printing and faxing to 702-486-6520; attention: Self Report. Retain a copy for your records.

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