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Incident Report Form - DOH

Government of the District of Columbia
Department of Health

Health Regulation and Licensing Administration
Office of Compliance and Quality Assurance

899 North Capitol Street, NE
2nd Floor, Suite 224
Washington, DC 20002
FAX TO: (202) 442-4924

FACILITY TYPE
Incident Categorization:
EVENT OR INCIDENT DESCRIPTION

DESCRIBE EVENT OR INCIDENT (INCLUDE DATE, TIME, LOCATION, PERPETRATOR, NATURE OF INCIDENT, ANY ANTECEDENTS LEADING UP TO INCIDENT AND HOW CLIENTS WERE AFFECTED, INCLUDING ANY INJURIES

 

Event or Incident description (Continued)
Reporter Information
Report Reviewed/Approved by
Agencies/Individuals Notified (Specify Name and Telephone Number)
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