AZDHS Reportable Event Form - Fill Out and Use This PDF

AZDHS Reportable Event Form PDF Details

The AZDHS Reportable Event Record Report is a legally mandated document issued by the Arizona Department of Health Services (ADHS). Long-term care facility administrators, healthcare providers, and nursing home staff are required to complete this form whenever a reportable event occurs at their facility. The Division of Licensing Services uses the completed reportable event record forms to monitor facility safety and ensure regulatory compliance across Arizona.

The form covers a wide range of incident types that must be reported. These include elopement, injuries of unknown origin, environmental emergencies, neglect, financial exploitation of a resident, physical or verbal abuse, sexual abuse, and unexpected deaths. Each incident category has its own designated section in the reportable event record, making it easier for facility staff to accurately document the nature of the event.

When filling out the AZDHS reportable event record, the reporter must document the exact date and time the event occurred, whether the incident meets the threshold for a significant event, and a complete list of parties who were notified. Notification details must include law enforcement or a police department (with the case number and officer name), the Nursing Board, Adult Protective Services (APS), the attending physician, the Pharmacy Board, family members or guardians, the Medical Examiner if applicable, and ADHS itself.

If the event involves an allegation of abuse, neglect, or misappropriation of resident funds, the form includes a dedicated section for information about the alleged perpetrator. This section requests the person's last name, first name, alias, street address, telephone number, date of hire, and whether the individual has been suspended pending investigation.

Arizona regulations require that this reportable event form be completed and submitted to the Division of Licensing Services within five days of the event. Timely and accurate reporting supports the health, safety, and welfare of all residents in licensed long-term care facilities across Arizona. Facilities that fail to file within the required window may face regulatory penalties from the Arizona Department of Health Services.

The reportable event record includes four pages covering incident identification, staff notifications, perpetrator information if applicable, and a full narrative section. The narrative section gives facility administrators the opportunity to describe exactly what happened, what immediate steps were taken, and the outcome for the resident involved. Completing every section of this form thoroughly is critical for ADHS to conduct an accurate investigation.