The form was created for use by facilities to self-report alleged violations of neglect and abuse, including injuries of unknown source, and misappropriation of resident
property/funds (refer to April 12, 2005 memorandum from Carol Benner regarding
the clarification of reporting
requirements). It is not mandatory that facilities use this form, but a facility must include, at a minimum, the information requested on this form.
The form should be used to forward both the “first report” and “results of investigation” to the OHCQ/Long Term Care Unit via fax 410-402-8113 or email firstname.lastname@example.org
The facility should complete the top of the form for the “first report” and forward to OHCQ within 24 hours of the incident.
The results of the investigation of the reported incident, should then be entered on the bottom of the form and be forwarded to OHCQ. One complete form (i.e., includes the first report and investigation results) should be forwarded within 5 days of the incident.
The Nursing Home Self-Report Form can be downloaded and viewed with Microsoft® or Word Adobe Acrobat®.