3613 A Provider Investigation Report Details

Form 3613 A, also known as the "Employee's Withholding Allowance Certificate," is a document used by employers to determine an employee's withholding allowances. The form must be completed by the employee and submitted to the employer. This article will provide an overview of Form 3613 A and instructions on how to complete it. It's important for employees to understand how their wages are taxed so they can plan ahead for their financial future. By completing Form 3613 A, employees can ensure that their correct withholding allowances are being taken into account by their employer.

The listing provides details about the form 3613 a. Before you decide to fill out the form, it is definitely worth examining a little more about it.

QuestionAnswer
Form NameForm 3613 A
Form Length4 pages
Fillable?Yes
Fillable fields240
Avg. time to fill out24 min 32 sec
Other namestexas form 3613 a, form 3613 provider investigation report, 3613 a provider investigation report, dads forms

Form Preview Example

Provider Investigation Report

For use only by Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individual with an Intellectual Disability or Related Conditions (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS).

Fax Cover Sheet

Date:

To: DADS Consumer Rights and Services Section

Attention: Intake Coordinator

Fax Area Code and Telephone No.: 1-877-438-5827

Regarding DADS Intake ID No.:

No. of Pages, including cover:

 

 

From:

 

 

 

 

 

 

Provider Name:

 

 

 

Vendor / ID No.:

 

Street Address:

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

Telephone No.:

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Investigation Report Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Name

 

 

 

 

 

 

License No.

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, ZIP Code

 

 

 

 

 

County

 

 

 

 

 

 

Area Code and Telephone No.

 

Fax Area Code and Telephone No.

 

 

 

 

 

Parent

Branch/Alternate Delivery Site

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confidential Document:

This communication (including any attached document) contains privileged and/or confidential information. If you are not an intended recipient of this communication, please be advised that any disclosure, dissemination, distribution, copying or other use of this communication or any attached document is strictly prohibited. If you have received this communication in error, please notify the sender immediately and promptly destroy all copies of this communication and any attached documents.

Use only for Skilled Nursing Facilities (SNF), Nursing Facilities (NF),

Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID),

Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC),

and Day and Activity Health Services Facilities (DAHS).

Form 3613-A/ 07-2012

Texas Department of Aging

SNF, NF, ICF/IID, ALF, ADC, DAHS

and Disability Services

Provider Investigation Report

 

Fax this report to: 1-877-438-5827 (toll free) or

Mail this report to: Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030

Form 3613-A

July 2012

Note to reporter:

Do not mail if faxed.

DADS Intake ID No.

 

Date Reported to DADS 800-458-9858

 

 

Time Reported

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

 

A.M.

P.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Type

 

 

 

 

Vendor / ID No.

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

City

 

 

 

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident Category

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Death

Abuse

Neglect

Exploitation

Missing Resident/Individual

Drug Diversion

 

Fire

Bomb Threat

 

Tornado

Flood

Emergency Power Failure

Sprinkler System Failure

Fire Alarm Failure

Firearms in the Building

Air Conditioning Failure if Outdoor Temperature is or will be 90 Degrees or Above

 

 

 

 

 

 

 

 

 

Heating System Failure if Outdoor Temperature is 65 Degrees or Below

 

 

 

 

 

 

 

 

 

Others, specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who made the allegation?

 

 

 

 

 

 

 

 

 

When?

 

 

 

 

Individual /Resident

Family

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident Date

 

 

Time

 

 

Location

 

 

 

 

 

 

 

 

 

 

 

 

:

A.M.

P.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s)

Name

 

 

 

 

 

 

Female

 

Male

Social Security No.

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional Ability:

Total assistance

 

Extensive

 

Minimal

 

No assistance

 

 

Level of Supervision:

No special supervision

Within eyesight

 

Within hearing

Within arm’s length

 

 

 

 

Within specified distance:

 

 

 

Specified observation time frame:

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independently ambulatory

Y

N

Interviewable

Y

N Capacity to make informed decisions

Y

N

History of

Combativeness

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

 

 

 

Wandering

Wearing wander guard at time of incident

Y

N

Similar allegations

 

 

 

Other pertinent history:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

Female

 

Male

Social Security No.

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional Ability: Level of Supervision:

Total assistance

No special supervision Within specified distance: Other:

Extensive

Minimal

No assistance

Within eyesight

Within hearing

Within arm’s length

 

Specified observation time frame:

 

 

 

Independently ambulatory

Y

History of

Combativeness

 

 

Wandering

 

Other pertinent history:

N

Interviewable

Y

N

Capacity to make informed decisions

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

Wearing wander guard at time of incident

Y

N

Similar allegations

Y N

Name

 

 

 

 

 

 

Female

 

Male

Social Security No.

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional Ability:

Total assistance

 

Extensive

 

 

Minimal

 

No assistance

 

 

Level of Supervision:

No special supervision

Within eyesight

 

 

Within hearing

 

Within arm’s length

 

 

 

 

Within specified distance:

 

 

 

 

Specified observation time frame:

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independently ambulatory

 

Y

N

Interviewable

Y

N

Capacity to make informed decisions

Y

N

History of

Combativeness

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

 

 

Wandering

Wearing wander guard at time of incident

 

Y

N

Similar allegations

 

 

 

Other pertinent history:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 3613-A

Page 2 / 07-2012

DADS Intake ID No.

Alleged Perpetrator(s) (AP)

(If alleged perpetrator is somebody other than a staff member, indicate this individual’s relationship to the person. Example: relative, visitor, etc.)

Name

Date of Birth

Social Security No.

License/Certificate No.

 

How was the AP identified?

By name

By description

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Perpetrator:

Denied

Confirmed

History of similar allegations?

 

Yes

No

 

 

Did investigation reveal the presence of a witness?

 

 

 

Yes

No

 

 

 

 

 

 

 

Statement attached (signed and notarized, if possible)

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness(es) Name

Individual/Patient/Family/Staff/Other

Address

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of the Allegation

....................................................................................................................................................Injury/Adverse Effect?

Yes

No

 

 

 

Description of Injury

 

 

 

 

 

Assessment

Date

Time

:

A.M.

P.M.

Description of Assessment

 

 

 

Treatment/Transfer Date

Time

 

 

Treatment provided?

Yes

No

 

:

A.M.

P.M.

 

 

 

Off-site

 

City

 

Treatment location: In-House

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Provider Response

Form 3613-A

Page 3 / 07-2012

DADS Intake ID No.

Investigation Summary (attach additional sheets, as necessary)

Investigation Findings

Confirmed

Unconfirmed

Inconclusive

Unfounded

Provider Action Taken Post-Investigation

Signature

Printed Name

Title

Date

How to Edit Form 3613 A

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Complete the texas 3613 PDF by typing in the details needed for every single section.

example of empty fields in texas health and human services for 3613a

Put the essential details in the Telephone No, Fax:, Provider Investigation Report, License No, County, Fax Area Code and Telephone No, Parent, Branch/Alternate Delivery Site, Agency Name, Street Address, City, Area Code and Telephone No, and Confidential Document: section.

Filling in texas health and human services for 3613a step 2

Note down the significant details when you are within the Date Reported to DADS 800-458-9858, Time Reported, Vendor / ID No, City, Telephone No, ZIP Code, Bomb Threat, Drug Diversion Fire Alarm Failure, Fire, Firearms in the Building, Abuse, Neglect, Missing Resident/Individual Death, Emergency Power Failure, Exploitation, Flood, Others, Who made the allegation, Individual /Resident, Family, Other, Incident Date, Location, Time :, Individual(s)/Resident(s), When, DADS Intake ID No, Provider Type Name, Street Address, and Incident Category field.

step 3 to entering details in texas health and human services for 3613a

The field Individual(s)/Resident(s), Functional Ability:, Level of Supervision:, No special supervision, Within eyesight, Within hearing, Total assistance, Extensive, Minimal, Female, Male, Social Security No, Date of Birth, No assistance Within arm’s length, Name, Within specified distance:, Other:, Specified observation time frame:, Independently ambulatory History of, Combativeness, Interviewable Verbal aggression, N Capacity to make informed, Physical aggression, Sexual misconduct, Wandering, Wearing wander guard at time of, Similar allegations, Other pertinent history:, Functional Ability:, Level of Supervision:, No special supervision, Within eyesight, Within hearing, Total assistance, Extensive, Minimal, Female, Male, Social Security No, Date of Birth, Within specified distance:, Specified observation time frame:, No assistance Within arm’s length, Other: N, Independently ambulatory, Interviewable, N Capacity to make informed, History of, Combativeness, Verbal aggression, Physical aggression, Sexual misconduct, Wandering, Wearing wander guard at time of, and Similar allegations will be for you to include all sides' rights and responsibilities.

step 4 to completing texas health and human services for 3613a

End up by looking at these fields and preparing them accordingly: Name, Functional Ability: Level of, Total assistance No special, Extensive Within eyesight, Minimal Within hearing, Specified observation time frame:, No assistance Within arm’s length, Within specified distance:, Other:, Female, Male, Social Security No, Date of Birth, Independently ambulatory, Interviewable, N Capacity to make informed, History of, Combativeness, Verbal aggression, Physical aggression, Sexual misconduct, Wandering, Wearing wander guard at time of, Similar allegations, and Other pertinent history:.

Filling in texas health and human services for 3613a part 5

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