On October 8, 2018, the Department of Homeland Security (DHS) released Form DHS 1147I. This new form is required for all individuals requesting an immigration benefit who are not U.S. citizens or lawful permanent residents. The form must be submitted with the application package and is used to determine the individual's eligibility for a specific benefit. Eligibility is determined by checking the applicant's criminal history and other factors such as whether they have ever been deported or removed from the United States. Form DHS 1147I replaces Form I-94, which was previously used to collect this information. It is important to note that the form will only be accepted if it is properly completed and signed. If you are uncertain about how to complete or sign the form, consult with an immigration attorney for assistance.
| Question | Answer |
|---|---|
| Form Name | Form Dhs 1147I |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Jan, ses, e16 category green card, e16 form |
DEPARTMENT OF HUMAN SERVICES |
P. O. Box 700190 |
Kapolei, HI 96707 |
INCIDENT REPORT
Reportable incident: (Submit within 72 hours of reportable incident.) Check appropriate box below. [ ] Absence without leave for one or more nights.
[] Adverse reaction to a drug, medication error and/or treatment.
[] Bodily injury requiring medical intervention.
1.Facility Name
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Resident Name |
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3. Sex |
4. Birthdate(mm/dd/yyyy) |
5. Acuity Level at time of incident |
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[ ]SNF [ ]ICF [ ]ICF/MR [ ]Other |
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Diagnosis(ses) |
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7. |
Date & Time of incident |
8. Place of incident (e.g., hallway, bedroom, dining area, etc.) |
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(Note: If more space is needed, continue at the back of this form.) |
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8. |
Description of incident: |
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9.Description of the kind & extent of medical intervention: (Include/attach results of diagnostic tests; e.g., xrays, M.D. assessment, etc.)
10.Corrective action(s):
11.Reported to other agency(ies); e.g., APS, DOH, MID: Yes [ ]____________________________________ No [ ] Name(s)
12.Name & Title of reporter: _________________________________________________________________________
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__________________ |
Signature |
Date |
13. If NO reportable incidents have occurred in the facility from Jan.- June or July - Dec., pls. complete below and submit by the 15th of the month following the end of the reporting period.
NO REPORTABLE INCIDENT: [ ] Jan. – June, Year __________ [ ] July – Dec., Year ________
Name & Title of reporter: __________________________________________ Facility Name: ___________________________________
________________________________________ Date: ___________________
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Signature |
DHS 1147i (2/2000) |
DO NOT MODIFY FORM |
PROVIDER MANUAL: APPENDIX 5 |
Pages E1 to E34 |
REPORTING AND ASSESSMENT FORMS |
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Incident Report |
Page E16 |
DHS 1147i |
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