Section 300.APPENDIX G Facility Report

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Facility Name ___________________________								Phone ___________________
Address ______________________________					City ______________				Zip __________
Facility-wide occurrence?	Yes		No				Resident Name ______________________________
							Age ________ M ___ F ___
Were other residents involved?		Yes		No		(Complete this form for each resident unless occurrence is facility wide.)

Type of occurrence:

1. Suspected abuse/neglect

2. Missing person

3. Communicable disease

4. Medication error

5. Unexplained death

6. Loss of essential staff

7. Fire

8. Bldg. emergency

9. Loss of essential utilities

10. Bomb threat

11. Serious injury

12. Sexual assault

13. Other ________________

Evacuation:

Yes ____ No ____

# of residents ____________________

evacuated from __________________

________________________________

Expected return __________________

________________________________

Status of resident:

Witness to occurrence:

Police Notified?

Doctor Notified?

Resident sent to hospital?

Resident Hospitalized?

Family/Guardian Notified?

Yes No

Comment: ________________________________________

Date: _____________ Hospital: ______________________

Comment: ________________________________________

Complete Description of Occurrence:

Further description attached?

Person completing form: ________________________________ Title: _____________________________

Form Faxed? Yes No Reported by phone? Yes No

by whom? ________________________________ by whom? _________________________________

date: ______________________ time: ________ date: ____________________ time: __________

(Source: Added at 26 Ill. Reg. 3113, effective February 15, 2002)