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"""$"8":"V"X"Z"\"""̿뿶뿶{뿶kjVhXph<>CJUjhXph<>CJUjh"UjߓhXph<>CJUjkhXph<>CJUhi=h"CJjhi=h"CJU h"CJjhXpUmHnHujh"Uh"jh"Uh1h"5*l!n!![R .$Ifgd0kdS$$IfT4ֈj! +q+64 af4yt"T!!!!"f"""neYee +$$Ifa$gd0 .$Ifgd0Ekdk$$IfT4D+++64 af4yt$T +$Ifgd0Ckd|$$IfT4+++64 af4yt0T"""""&#zqzz $Ifgdp +$Ifgd0|kdʗ$$IfT4\j$+q%&+64 af4yt0T""""""""""""""####"#$#f#h#|#~########$ $ $$$$$0$2$4$>$@$B$D$X$Z$\$f$h$r$t$$jh"Ujyh"Ujh"Uh h"5jmh"Ujh"Uj8h"UjhXpUmHnHujh"Uj˜h"Uh"4&#(#d#f##x5, +$Ifgd0Ckd$$IfT4+++64 af4yt0T .$Ifgd0~kd$$$IfT4\j$+q %&+64 af4yt0T#######5|kdT$$IfT4\~+ +64 af4yt0T .$Ifgd0Ekdכ$$IfT4+++64 af4yt0T#$B$j$%%&%xo .$Ifgd0~kd$$IfT4\~+ +64 af4yt}BT $Ifgdb\$$$$$$$$$$$$$$$$$%%(%*%>%@%B%L%N%%%%%%%%%%%%%&&4&6&8&:&R&T&ڹڬڬڬsڬjhXph<>CJUjhXph<>CJUj/hXph<>CJUhi=h"CJjhi=h"CJUjɠh"Uj-h"UjÞh"Uh"jhXpUmHnHujh"UjYh"U-&%(%P%R%%ne .$Ifgd0Ekd?$$IfT4+++64 af4yt$T $Ifgdb\CkdV$$IfT4+++64 af4yt$T%%~&&&kb .$Ifgd0Ekd$$IfT4+++64 af4yt$T $$Ifa$gdb\Ckd$$IfT4+++64 af4yt$TT&p&r&t&v&&& '''''v'x'''''''''''''( "$&*RTprtv|ε֪ε֐pj2hXph<>CJUjhXph<>CJUUh h"5jJhXph<>CJUjih"UjhXpUmHnHujh"Ujh"Uh"jhi=h"CJUjhXph<>CJUhi=h"CJ,&&' 't'lc +$Ifgd3Ekdo$$IfT4+++64 af4ytPT +$IfgdPEkd|$$IfT4+++64 af4yt0Tt'v'''Vl` $$Ifa$gd -EkdӦ$$IfT4D+++64 af4yt$T +$IfgdPEkd$$IfT4+++64 af4yt3T  FORMCHECKBOX  No Interviewable:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Capacity to make informed decisions:  FORMCHECKBOX  Yes  FORMCHECKBOX  NoKnown history of:Combativeness FORMCHECKBOX  Yes  FORMCHECKBOX  No Similar allegations FORMCHECKBOX  Yes  FORMCHECKBOX  No Wandering FORMCHECKBOX  Yes  FORMCHECKBOX  No Sexual misconduct FORMCHECKBOX  Yes  FORMCHECKBOX  No Verbal aggression FORMCHECKBOX  Yes  FORMCHECKBOX  No Physical aggression FORMCHECKBOX  Yes  FORMCHECKBOX  No Diagnosis/Pertinent History: FORMTEXT      Alleged Perpetrator(s) (AP): Attach copies of any criminal history check, nurse aide registry search and employee misconduct registry search conducted to verify the employability of the alleged perpetrator.Staff Name (includes family if employed by agency)Date of BirthSocial Security No.License/Certificate No. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      How was the AP identified? FORMCHECKBOX  By Name FORMCHECKBOX  By Description FORMCHECKBOX  Other: FORMTEXT      AP: FORMCHECKBOX  Denied FORMCHECKBOX  ConfirmedHistory of similar allegations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  DADS Intake ID No.Agency NameLicense No. REF IntakeID   FORMTEXT       FORMTEXT      Did investigation reveal the presence of a witness?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Statement attached (signed and notarized if possible)  FORMCHECKBOX  Yes  FORMCHECKBOX  No Witness(es) NameClient/Patient/Family/Staff/OtherAddressArea Code and Telephone No. FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT     Injury or adverse effect?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoAssessment DateTime FORMTEXT       FORMTEXT   : FORMTEXT    FORMCHECKBOX  A.M.  FORMCHECKBOX  P.M.Description of Injury/Assessment: FORMTEXT      Treatment provided?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoTreatment/Transfer DateTime FORMTEXT       FORMTEXT   : FORMTEXT    FORMCHECKBOX  A.M.  FORMCHECKBOX  P.MTreatment Location (name and complete address)In-House? FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  NoAgency Immediate Response FORMTEXT      Investigation Summary (attach additional sheets as necessary) FORMTEXT      Investigation Findings FORMCHECKBOX  Confirmed  FORMCHECKBOX  Unconfirmed  FORMCHECKBOX  Inconclusive  FORMCHECKBOX  UnfoundedAgency action post-investigation FORMTEXT      Note: DADS does not accept this report as complete until the reporter s signature, printed name, title and date have been entered below.SignatureTitle FORMTEXT      Printed NameDate FORMTEXT       FORMTEXT           Form 3613 Page  PAGE 2 / 10-2008 Form 3613 Page 2 / 10-2008  "(,.JLNPTħȧʧ$&BDFHNRTpٽ٭ٍٝ}jhXph<>CJUjphXph<>CJUjhXph<>CJUjhXph<>CJUjhXph<>CJUh"h h"5hi=h"CJjhi=h"CJUjhXph<>CJU*VX|~$jaaaaXaa $IfgdZ $Ifgd+Ekd$$IfT4+++64 af4yt+T $Ifgd+Ekd$$IfT4+++64 af4yt$T prtvzĨȨʨ ">@BDJNPlnprv©ĩƩ̩Щҩٽ٭ٍٝ}jhXph<>CJUjMhXph<>CJUjٮhXph<>CJUj@hXph<>CJUj̬hXph<>CJUh"h h"5hi=h"CJjhi=h"CJUjXhXph<>CJU* ,# $Ifgd+kd$$IfT4ִ! 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