Alaska Centralized Report

Reporter Information In this section, you will fill out your contact information so that we can contact you if we need additional information. For mandated reporters, we must have at least your name and a phone number to ensure that we can properly address your concern in case additional information is needed. If you choose to remain anonymous, please enter unknown in the first and last name fields and type in (000)000-0000 as the phone number since those fields are required. An anonymous Report of Harm can also be made by calling 1-800-478-9996. Mandated Reporter No Yes Agency Job Title First Name required Last Name required Middle Initial Address Type Business Address Care Of Address Mailing Address Residence Address Temporary Address Other City For Service Provider Reports Address Line 1 Address Line 2 City select select State select select Zip Code select select Borough select select Contact Phone Number required Extension Phone Type Cell Fax Home1 Other Work Secondary Phone Number Extension Phone Type Cell Fax Home1 Other Work Email Address Date of Birth Relationship to Involved Person Advanced Nurse Practitioner Advocate Agency Representative ALH Administrator Alternate POA Attorney Audiologist Aunt Back Up Care Coordinator Back Up PCA Bank Behavioral Therapist Board Certified Behavior Analyst Boyfriend Brother Brother-in-law Care Coordinator Care Planning Participant Care Provider Caregiver Case Manager Church/Clergy Co-Guardian Co-Habitant/Roommate Conservator Daughter Dentist Developmental Disability Registered Nurse (DDRN) Doctor Domestic Partner Emergency Contact-Primary Emergency Contact-Secondary Employer Father Father-in-law Fire Department Foster Parent Friend Girlfriend Grandchild Grandfather Grandmother Grandparent Guardian Health/Medical Professional Husband In-Law Interpreter/Translator Landlord Law Enforcement Lawyer Legal Decision Maker Legal Guardian Legal Representative Mother Mother-in-Law Neighbor Nephew Niece Nurse Occupational Therapist OPA Guardian Other Healthcare Provider Other Professional Parent Partner PCA PCS Representative Designee Personal Care Attendant Physical Therapist Physician Assistant Power of Attorney - Durable Power of Attorney - General Power of Attorney - Health Power of Attorney - PCA Primary Care Physician Psychiatrist Psychologist Referring Agency Relative - Other Representative Payee Respite Provider Self Service Provider Sibling Sister Sister-in-Law Social Worker Son Speech Therapist Spouse Step Brother Step Sister Surrogate Decision Maker Teacher Therapist Uncle Wife Relationship to Incident Alleged Perpetrator Alleged Victim First Responder Not Involved Other Participant Self Surrogate Decision Maker Witness Best Time to Contact Date incident became known to the Reporter required Reporter Requested Notification Yes Unknown No COVID-19 Screening 1. Is the allegation or report related to COVID-19? 2. Please describe why the allegation or report is related to COVID-19. 3. Is the alleged victim, or anyone in the home experiencing symptoms consistent with COVID-19 (fever, cough, shortness of breath, loss of appetite or diarrhea )? Yes No Don't Know Refused 4. When did your symptoms begin? 5. Have you, the alleged victim, or anyone in the home, had contact with someone who has had the flu, pneumonia, or confirmed COVID-19 in the last 14 days? Yes No Don't Know Refused 6. Has the alleged victim, or anyone in the home been asked to self quarantine or isolate? If yes, Date? If No, end. Yes No Don't Know Refused 7. Date asked to self quarantine or isolate. 8. Please describe why alleged victim (or anyone in the home) was asked to self quarantine or isolate. 9. Has alleged victim been tested for COVID-19? If yes, then following Questions, if no, end. Yes No Don't Know Refused 10. If known, what is the COVID-19 test result or confirmed disease status? Positive - Confirmed to have COVID-19 Negative - Confirmed Not to have COVID-19 11. If tested for COVID-19, what date were the test results provided to you? 12. What is your current symptomatic disposition? Currently symptomatic No longer symptomatic Confirmed Recovery Deceased 13. Current symptomatic disposition date: Incident Information In this section, you will describe what caused you to fill out a report on the involved person. If anyone saw the incident happen, you will need to add their contact information to the Other Participant Section. Please answer as many of the following questions as you can. Incident Date Incident Time : Incident Location required Alleged Victim Home Community Community Care/Day Care Facility Community Program Correctional Institution Home Based Care Home of Non-Relative Home of Relative Homeless Shelter Hospital Licensed Assisted Living Nursing Facility Other Rehabilitation Facility State Institution Unknown Unlicensed Assisted Living Agency Incident Phone Address Line 1 Address Line 2 City select select State select select Zip Code select select Borough select select Law Enforcement Involvement Notification - Emergency Notification - Non-Emergency Notification - Not Necessary Previously Notified Result of Incident Sending Additional Documentation Via U.S. Mail Fax Separate Email Please describe the incident in details and include the following information. What happened? (Describe the circumstances leading to the incident or death.) What did you or others do when it happened and how will you or others help the participant now? (In cases of death, please also tell us who was present or discovered the death.) What do you think was the cause of the incident? (In cases of death, what were the health or safety issues that contributed to the death such as illnesses, hospitalizations, or accidents?) What could be changed, or has been changed so a similar incident does not happen again? Was there an emergency response? (Describe who called 911 or other emergency services and what was done for the participant upon arrival. If the participant was taken to the emergency room as a result of incident or prior to death describe how they were transported.) In case of death, please describe if the participant is enrolled in Comfort One, has a DNR in place or receiving hospice services (please provide the name of the hospice provider.) Risk to Investigator No Unknown Yes If Yes, please explain. Alleged Victim/Involved Person/Affected Resident Add Edit Edit Delete Delete Alleged Perpetrator/Other Involved Person/Staff Involved Add Edit Delete Edit Delete Other Participant/Additional Contact/Collateral Contact Add Edit Delete Edit Delete Attachments Add Add Delete Delete

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