P.O. Box C, Lawrence, KS 66044Name of Affected Person/Ward:                          Date:Address where housed:           ...
Supporting documents:   o   Photo   o   Video   o   Audio Recording   o   Records/Documents   o   Witness   o   Other ____...
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Medical whistleblower neglect abuse incident report

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Medical whistleblower neglect abuse incident report

  1. 1. P.O. Box C, Lawrence, KS 66044Name of Affected Person/Ward: Date:Address where housed: Where it occurred:State and Zip Code: Time:Country: USA Who observed it?Observation/Incident:Abuse: o Mental Neglect: Incident Observed o Physical o Bed Sores o Physical Assault o Emotional o Urinary Tract o Sexual Assault o Verbal Infection o Rape o Sexual o Dehydration o Verbal AssaultSoiled: o Malnutrition o Other o Yes o Skin rash o No o Fecal Impaction Vital Signs: o Urine o Falls o Feces o Fractures Temperature: o Saliva Drooling o Skin Tears/Cuts o Infections Weight:Description of Observation/Incident: (attach additional sheets if necessary)Name of person responsible for maltreatment:How long has abuse been occurring? Neglect/Abuse Incident Report page 1
  2. 2. Supporting documents: o Photo o Video o Audio Recording o Records/Documents o Witness o Other _______________________________Facility Name:Shift Supervisor:Location in the facility where observations occurred:Reported to: o Facility Administrator o Police o Director of Nursing o State Officials o Charge Nurse o Federal Officials o Facility Social Services o Other o Certified Nursing Assistant ________________________________ ____________Include names of all individuals involved or case #___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signed: _________________________________________________ Date: _______________________Witness: ________________________________________________ Date: _______________________Notarized: Neglect/Abuse Incident Report page 2

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