Azdhs Reportable Event Form PDF Details

The Azdhs reportable event form is a document that must be completed by all providers when an event occurs that meets the definition of a reportable event. Providers have a responsibility to submit this form as soon as possible, and no later than 24 hours after the event has occurred. This document outlines specific information about the event, including who was involved, what happened, and any potential consequences. Completing this form accurately and promptly can help ensure that incidents are properly investigated and resolved.

Form NameAzdhs Reportable Event Form
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesazdhs reportable event form, event record report, az dhs reportabl e events, az dhs reportable event form

Form Preview Example

Ar izon a Depar t m ent of Healt h Ser vices

Confident ial File

Div ision of Licensing Ser v ices

Dat e: ________

Long Ter m Car e Licensing

I nit : _________

150 N. 18t h Av e. , St e. 440


Phoenix , AZ 85007


Phone: ( 602) 364 - 2690


Aft er Hour s: ( 602) 364 - 2677


Fax: (602) 324-0993



Please answ er ALL quest ions fully and addr ess only one ev ent per r epor t .

Complete Investigations Include: staff,resident, and witness interviews as well as ALL pertinent information.

* * * Subm it v ia Fax w it hin 5 day s of ev ent * * *

Today 's Dat e ( m m / dd/ yy y y )

Dat e of Ev ent ( m m / dd/ y y y y)

Tim e of Ev ent



Was t his a significant ev ent ?



Was significant ev ent called in?



Full Nam e of Facilit y

St r eet Addr ess

Cit y

St at e

Zip Code

Facilit y Telephone Num ber

Facilit y License Num ber

Provider ID/CCN

Per son Repor t ing

Tit le

Ty p e of I n cid e n t (check all that apply):



Elopem ent





I nj ur y Unk now n Or igin







Env ir onm ent al Em er gency






















Financial Ex ploit at ion





Resident Car e

















I nj ur y





Resident - t o- Resident

















I ncident





Abuse St aff - t o- Resident

















I nv olunt ar y Dischar ge





Abuse Unex pect ed Deat h











Ot her , Specify :



























































W h o w a s n ot if ie d of t h e occu r r e n ce (check all that apply)?







Law Enfor cem ent - Police Dept . Nam e


Case Num ber


























Nur sing Boar d

Fam ily / Guar dian




Ot her








Medical Examiner











Phy sician

Om budsm an











Phar m acy Boar d

ADHS (Name of surveyor you spoke to and time you called.)















































Revised 11/07/2017

Page 1 of 4



I s t he ev ent an allegat ion of abuse, neglect or m isappr opr iat ion of funds? I f y es, com plet e t h e Alleged Perpetrator Information Section.




Nam e:


Fir st



Addr ess:

St r eet / Box

Cit y

St at e


Telephone Num ber

Dat e of Hir e (mm/dd/yyyy)

AP Suspended?



Dat e (mm/dd/yyyy)

AP Ter m inat ed?



Dat e (mm/dd/yyyy)


Cer t ificat e or License No.

Ty pe of Cer t ificat ion ( check all t hat apply )

Nur se Aid ( NA)

Cer t ified Nur se Aid ( CNA)

Regist er ed Nu r se ( RN)

Licensed Pr act ical Nur se ( LPN)

Ot her ( specify t y pe: )




Resident Nam e

Dat e of Adm ission (mm/dd/yyyy)

Dat e of Bir t h (mm/dd/yyyy)

Ex a ct Loca t ion of I n cid e n t

N a r r a t iv e :

1)Descr ibe t he ev ent , including t im efr am es/ r isk fact or s r elat ed t o t he incident / ev ent ( r elev ant r esident dx and cognit iv e st at us. If resident to resident altercation is this the first time the resident was involved in an altercation?)

Revised 11/07/2017

Page 2 of 4



2 ) Pr ior t o t he ev ent , w as a plan of car e dev eloped t hat addr essed t his issue, and w er e planned

int er v ent ions in place w hen t he ev ent occur r ed? For ex am ple, a chair alar m or a lap buddy in place.


No Please descr ibe:


What int er v ent ions w er e im plem ent ed aft er t he incident / ev ent ? For ex am ple, super v ision, r esident sent

t o

hospit al, CNA suspended . Please descr ibe inv est igat iv e findings/ conclusions:

Revised 11/07/2017

Page 3 of 4



Facilit y I nv est igat ion Repor t for Rr esident Abuse, Neglect , Misappr opr iat ion of Pr oper t y , And Ex ploit at ion

of Resident s in Long - Ter m Car e Facilit ies

Use Separ at e sheet for each w it ness/ per son int er v iew ed

W it n e ss St a t e m e n t For m

Dat e:

Tim e:








Wit ness Full Nam e:










Job Tit le:


Shift :








Hom e Addr ess:


Cit y / Zip








Hom e Ph one # :


Wor k Ph one # :








Relat ion t o Resident : ( I f any )





St at e in y our ow n w or ds w hat y ou w it nessed ( be v er y descr ipt iv e) and sign below .

The infor m at ion pr ov ided abov e is t r ue t o t h e best of m y k n ow ledge.

Signat ur e of Wit ness

Dat e



Revised 11/07/2017

Page 4 of 4

How to Edit Azdhs Reportable Event Form Online for Free

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1. The arizona department of health services reportable event form necessitates specific details to be entered. Make sure the next blanks are filled out:

Filling in part 1 in azdhs reportable event form

2. Now that the previous section is complete, you'll want to put in the needed specifics in Elopem ent Environm ent al Em, I nj ury Unknown Origin Neglect, W h o w a s n ot ifie d of t h e, Law Enforcem ent Police Dept Nam, Case Num ber, Officer, Nursing Board, APS Physician Pharm acy Board, Fam ily Guardian Medical Examiner, Ot her, Revised , and Page of in order to proceed to the next step.

The best way to fill in azdhs reportable event form stage 2

It is easy to make a mistake when filling in the Officer, hence make sure you reread it before you'll finalize the form.

3. Completing I s t he event an allegat ion of, Yes, ALLEGED PERPETRATOR I N FORM ATI, Last, First, Alias, Addr ess, St reet Box, Cit y, St at e, Zip, Telephone Num ber, Dat e of Hire mmddyyyy, AP Suspended, and Yes is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Learn how to complete azdhs reportable event form portion 3

4. Completing Nurse Aid NA Regist er ed Nurse , Cert ified Nurse Aid CNA Licensed, Resident Nam e, Dat e of Adm ission mmddyyyy Dat e, Ex a ct Loca t ion of I n cide n t, and N a r r a t iv e Descr ibe t he is vital in the next step - you'll want to take the time and be attentive with each field!

azdhs reportable event form writing process explained (part 4)

5. This final notch to conclude this form is critical. You must fill out the appropriate fields, and this includes Yes, No Please describe, and What int ervent ions w er e im, before finalizing. Or else, it may end up in a flawed and potentially invalid document!

Filling in segment 5 of azdhs reportable event form

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