INJURY OF UNKNOWN ORIGIN - INVESTIGATION REPORT by 83Oge4Yp

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                              INJURY OF UNKNOWN ORIGIN - INVESTIGATION REPORT
                                                          PART I
Consumer:
Program:
Date Injury Discovered:                                           Time:
Description of Injury:




Immediate Protective & Corrective Action(s): Include Medical Evaluation/Treatment Provided




Part I Completed by: (Name and Title)                                                                                    Date:
                                                       Part II
Staff Interviewed: (Please indicate staff name, title & shift)
           Days                      Evenings                                      Overnights                               Other



Preliminary Investigation (Findings): Include documents reviewed (i.e. – communication logs , behavioral data, etc) review of potential
environmental hazards, etc.




Part II Completed by: (Name and Title)                                                                                   Date:
                                                                   Part III
Follow-Up:


Conclusions & Recommendations:



Part III Completed by: (Name and Title)                                                                                  Date:
                                                                  PART IV
Reviewed by QA:
Name and Title:                                                              Date:
Comments:




             ___ Further investigation necessary                     ___ No further investigation necessary – case closed.

                                  Please attach incident report and all relevant documentation
     Please use additional sheet of paper if necessary.




Please attach incident report and all relevant documentation

								
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