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[DOT File]Report of Actual or Suspected Child Abuse or Neglect - DHS ...
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Phone Number 19. Reporting Person’s Name Report Code (see above) 19a. Name of Reporting Organization (school, hospital, etc.) 19b. Address (No. & Street) 19c. City 19d. State 19e. Zip Code 19f. Phone Number TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE 20. Summary Report and Conclusions of Physical Examination ...
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[DOCX File]APPENDIX H: MANDATED REPORTING REQUIREMENTS - …
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Immediately or as soon as possible by telephone, followed by a written report within two (2) working days. Failure to Report Failure to report, impeding or inhibiting a report of, physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder is a misdemeanor, punishable by six months in the county jail and a fine of ...
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[DOC File]Report of Job Injury or Illness - Oregon WCD
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Insert self-insured employer and insurer name, address, phone number, and service company, if any. Report of Job Injury or Illness. Workers’ compensation claim Worker. To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer.
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[DOC File]Name Phone number - Kalamazoo Public Safety
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(22) A copy of the report you filed with the police or sheriff’s department. If you are unable to obtain a report or report number from the police, please indicate that in Item 19. Some companies only need the report number, not a copy of the report. You may want to …
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[DOT File]STD-11, Confidential Sexually Transmitted Disease Report
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CONFIDENTIAL SEXUALLY TRANSMITTED DISEASE REPORT . form, please go to: nj.gov/health/std/ CONTACT INFORMATION: New Jersey Department of Health. Sexually Transmitted Disease Program. PO Box 363. Trenton, NJ 08625-0363. PHONE: (609) 826-4869
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Reporting Abuse and Neglect Committed against Persons …
Phone number. Specifics regarding the victim’s disability(ies) and care that is needed. Information regarding the victim’s competency. Name, address and telephone number of guardian if victim has a guardian. Identify any state agency that is involved with the victim. Current location of the victim. Information on the abuser: Complete name ...
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[DOC File]Insurer's Report - Oregon WCD
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Provide the actual name of the insurance company or self-insured employer responsible for the claim, the service company (if applicable), and claims processing address and phone number. Claim identifiers: Provide the worker’s name, address, Social Security number (SSN), date of injury, and claim number.
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[DOC File]Anti Fraud Annual Report - Mike Kreidler
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Dec 31, 2020 · Phone Number: _____ Form must be returned to our office by March 31st. By mail: Carolyn Cronin. Office of the Insurance Commissioner, State of WA. 810 3rd Ave., Suite 650. Seattle, WA 98104. By fax: (206)587-4244
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[DOC File]Spill Reporting Information Form - Template
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Insert Company’s own logo or name SPILL REPORTING INFORMATION FORM (template) Provincial Emergency Program (PEP): 1-800-663-3456 This template is based on the reporting information required under the B.C. Spill Reporting Regulation and is for your information only.
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[DOCX File]Sample Written Program for Emergency Action Plan
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It is ideal to have a hard-wired telephone in the room(s) you select. Cellular telephone equipment may be overwhelmed or damaged during an emergency. Call emergency contacts and have the telephone available if you need to report a life-threatening condition.]
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How to report a phone number