F 62447 Form – Fill Out and Use This PDF

F-62447 (05/2020)

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V.LAW ENFORCEMENT INVOLVEMENT (Page 6)

Check if law enforcement was contacted or is involved. Indicate the officer’s name, department, address, telephone number, and---if available---the case number. Attach a copy of the law enforcement incident report, if available.

VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT (Page 6)

Include all persons with specific knowledge of the incident. Include the person’s name, gender, address, and telephone number. Check whether the person is an entity employee. Include the person’s position at the entity or relationship to the affected person. Attach additional pages, as necessary.

VII. DESCRIBE OR ATTACH A COPY OF THE ENTITY’S INVESTIGATIVE RECORDS CONCERNING THE INCIDENT (Page 7)

Provide all relevant information found during the entity’s internal investigation, including the following:

STAFF INFORMATION

•Accused individual’s personnel records, including but not limited to training records, disciplinary records, time cards or sheets for the period during which or date(s) the incident occurred

•Witness time cards or sheets for the period or date(s) the incident occurred

•Staff schedule, roster, or assignment sheets for the time period or date(s) the incident occurred

•Statements from the accused individual and witnesses relating to the incident

•Sign-off sheets indicating completion of cares pertinent to the incident

ENTITY INFORMATION

•Entity’s policies and procedures related to the incident

•Photographs and diagram or illustration of the scene where the incident occurred with relevant information included, i.e., locations of witnesses, client, and pertinent objects at the time of the incident

CLIENT INFORMATION

•Pertinent medical records, including but not limited to the person’s plan of care or treatment plan at the time of the incident

•Ambulance run report, if applicable

•Any relevant hospital admission and discharge documents

•Photographs of visible injuries or affected property

•Financial account statements, including account numbers and balance information

•Statements about the incident

LAW ENFORCEMENT INFORMATION

•Law enforcement officer’s narrative reports

•Photographs

OTHER INFORMATION

Any other records that may apply

VIII. PERSON PREPARING THIS REPORT (Page 7)

Provide the name, position or title, and telephone number of the person preparing this report. The person preparing this report must sign and date this form in the space provided.

IX. WRITTEN STATEMENT (Page 8)

•Ask the affected client, the accused person, and all other persons with information about the incident to provide written statements.

•If the entity uses its own forms to obtain written statements about the incident, the entity may attach those forms to the Incident Report. If the entity attaches its own written statements to the report form, the facility should ensure that each person completing a written statement provides the identifying information requested on the report form and signs the statement.

•The entity is advised to follow up on written statements by asking probing questions to gather as much detail as possible, including what happened, how the incident happened, when it happened, where it happened, reactions at the time of the incident, and other witnesses who may have been present. It is suggested that the entity use the FOLLOW UP QUESTIONS (Page 9) following the written statement form as a guide when questioning the accused person.

F-62447 (05/2020)

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MISCONDUCT INCIDENT REPORT

Completion of this form is required by Wis. Admin. Code § DHS 13.05(3)(a). Failure to file a complete and accurate report of an incident of alleged misconduct, as required, may subject the entity to forfeiture or other sanctions specified by the Department under § DHS 13.05(3)(e) and may delay the investigation process. Personal information will be used to investigate the reported incident and the results of the investigation may be shared with other authorized investigative agencies.

This report form must be completed in its entirety. Additional information may be attached.

TYPE OR PRINT NEATLY IN BLACK INK.

I. ENTITY INFORMATION

Name – Entity or Facility

II. SUMMARY OF INCIDENT

INDICATE when the incident occurred. If the exact date and time are unknown, make a reasonable estimate and indicate that the date and time are estimated. Include the date the incident was discovered, if other than the date the incident occurred.

BRIEFLY DESCRIBE THE INCIDENT in the space below. Summarize the incident here even if additional documentation is attached.

DESCRIBE THE EFFECT that the incident had on the affected person, the person’s reaction to the incident, and the reaction of others who witnessed the incident.

F-62447 (05/2020)

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EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct.

CHECK the specific location where the incident happened.

At Your Entity

During Transport

Another Location – Explain.

III. AFFECTED PERSON INFORMATION (If more than one, include additional pages.)

If the affected person is adjudicated incompetent, under age 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of parent, guardian, or legal representative.

Name - Parent, Guardian, or Power of Attorney

Telephone No.

IV. ACCUSED PERSON INFORMATION (If more than one, include additional pages.)

Name – Accused Person (if known)		Date of Birth (MM/dd/yyyy)		Sex		Home Telephone No.
				M	F
Position, Title, or Relationship to Affected Person (at the time of the incident)						Social Security No.
Non Credentialed Staff	Credentialed Staff	Resident	Other (Specify.)

List any known credential held by accused at time of incident; e.g., RN, LPN, social worker, security guard, professional counselor.

NOTE: If employer is other than the reporting entity, provide information about accused person’s current employer.

NOTE: If accused person is under 18, provide parent(s) or guardian information.

Name(s) – Parent or Guardian		Sex		Telephone No.
		Male	Female
Street Address	City			State	Zip Code

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V. LAW ENFORCEMENT INVOLVEMENT

Was law enforcement contacted or involved?

No	Yes If “yes,” complete the following. Attach copy of the law enforcement incident report, if available.

VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT If more space is necessary, attach additional pages.

Name – Person who REPORTED Incident to the Entity					Sex		Telephone No.
					Male	Female
Street Address			City				State	Zip Code
Is this person an ENTITY EMPLOYEE?	Yes	No
Position in the Entity or Relationship to the Affected Person:
Name – Person with Information About the Incident					Sex		Telephone No.
					Male	Female
Address			City				State	Zip Code
Is this person an ENTITY EMPLOYEE?	Yes	No
Position in the Entity or Relationship to the Affected Person:
Name - Person with Information About the Incident					Sex		Telephone No.
					Male	Female
Address			City				State	Zip Code
Is this person an ENTITY EMPLOYEE?	Yes	No
Position in the Entity or Relationship to the Affected Person:
Name - Person with Information About the Incident					Sex		Telephone No.
					Male	Female
Address			City				State	Zip Code
Is this person an ENTITY EMPLOYEE?	Yes	No
Position in the Entity or Relationship to the Affected Person:
Name - Person with Information About the Incident					Sex		Telephone No.
					Male	Female
Address			City				State	Zip Code
Is this person an ENTITY EMPLOYEE?	Yes	No

Position in the Entity or Relationship to the Affected Person:

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VII. DESCRIBE BELOW OR ATTACH COPY OF ENTITY’S INVESTIGATIVE RECORDS CONCERNING INCIDENT.

VIII. PERSON PREPARING THIS REPORT (TYPE or PRINT neatly in BLACK INK.)

Position in the Entity or Relationship to the Affected Person:

SIGNATURE – Person Preparing This Report

Date Signed (MM/dd/yyyy)



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IX. WRITTEN STATEMENT

•Use this page to collect written statements from the accused person, affected person, and witnesses regarding incidents of alleged misconduct (abuse or neglect or misappropriation of property). Make additional copies of this page as necessary.

•Completion of this form is voluntary.

•It is suggested that entities ask the questions on the following page to obtain additional information and detail about reported incidents. Record all responses given.

•Entities may use their own forms; however, any written statement must be attached and submitted with the Misconduct Incident Report (DQA form F-62447).

Section 1 (To be completed by Entity)

Brief Description of Alleged Incident (e.g., “Marion R’s broken arm,” “the theft of Marion R’s credit card,” “Marion R’s fall.”)

Section 2 (To be completed by Accused Person, Affected Person, or Witness)

Full Name (Last, First, Middle Initial)	Work Telephone No.	Home Telephone No.
Street Address	City	State	Zip Code

Position or Title or Relationship to the Affected Person:

Section 3 (To be completed by Accused Person, Affected Person, or Witness)

Provide as much information as you know about the incident described above in detail. Use additional pages, as needed.

Check if additional pages are included.

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FOLLOW UP QUESTIONS TO BE ASKED BY THE ENTITY

It is suggested that entities ask the following questions to obtain additional, detailed information about reported incidents. Record all responses in the space provided. Attach additional pages, information, documentation, diagrams, photographs, or other evidence as appropriate.

Check if additional pages are included.

Check if items or documents are attached.

Check if a photocopy of an item or document is attached.

Check if an item or document is being retained by the entity; describe where and how it is being stored pending the outcome of this investigation.

How do you know about the above incident? Did you do it? Did it happen to you? Did you see it? Did another person tell you of it? If so, who?

Time and date of the incident. When did it happen? When did you first learn about it?

Location. (Where did the incident occur? Where were you when it happened? If others were present, who and where were the others? Where were you when you learned about it or saw it? Describe the location. Attach a diagram.)

Was anyone else present when it happened, you learned about it, or when you saw it? If so, who? Where was each person?

Did you tell anyone about the incident? If so, what did you tell them, who did you tell and when did you tell them? What did the person say, if anything?

Was anyone harmed in any way (physically or sexually, emotionally or mentally, or financially) or could someone have been harmed? If so, describe the harm or potential harm.

Were others harmed in any way? If so, identify the person who was harmed and describe the harm.

Describe the affected person’s actions or reactions during the incident including statements made, changes in demeanor, or other indications of pain, fear, sadness, anger, humiliation, etc.

Describe the actions or reactions of others who observed or were involved in the incident.

For Affected Persons: Did you tell anyone about what happened to you? If so, who did you tell and when and where did you tell them?

For Other Witnesses: Is or was the affected person able to report or talk about the incident?

If so, did the affected person say anything to you? If so, what? Describe the way that the affected person acted when telling you about the incident.

To your knowledge, did the affected person tell anyone else? If so, who and when?

Are there others who know or may know about the incident? If so, who are they and why do you think they have information about the incident?

Do you have or are you aware of any evidence, documentation or information that may be relevant to the incident? (Examples: photos, diagrams, maps, receipts, video tapes, audio tapes, medical records, care plans, financial transaction records, etc.) If so, what is it and where is it?

Additional Information