G Facility Report

Section 300.APPENDIX G   Facility Report ILLINOIS DEPARTMENT OF PUBLIC HEALTH Facility Name ___________________________ Phone ___________________ Address ______________________________ City ______________ Zip __________ Facility-wide occurrence? Yes No Resident Name ______________________________ Age  ________ M ___ F ___ Were other residents involved? Yes No (Complete this form for each resident unless occurrence is facility wide.) Type of occurrence: 1.   Suspected abuse/neglect 2.   Missing person 3.   Communicable disease 4.   Medication error 5.   Unexplained death 6.   Loss of essential staff 7.   Fire 8.   Bldg. emergency 9.   Loss of essential utilities 10.  Bomb threat 11.  Serious injury 12.  Sexual assault 13.  Other ________________ Evacuation: Yes ____ No ____ # of residents ____________________ evacuated from __________________ ________________________________ Expected return __________________ ________________________________ Status of resident: Witness to occurrence: Police Notified? Doctor Notified? Resident sent to hospital? Resident Hospitalized? Family/Guardian Notified? Yes No Yes No Yes No Yes No Yes No Comment: ________________________________________ Comment: ________________________________________ Comment: ________________________________________ Date: _____________ Hospital: ______________________ Comment: ________________________________________ Complete Description of Occurrence: Further description attached? Person completing form: ________________________________ Title: _____________________________ Form Faxed? Yes No Reported by phone? Yes No by whom? ________________________________             b y whom? _________________________________ date: ______________________ time: ________ date: ____________________ time: __________