DHSR/HCPR Form No. 4500 Rev. 06/24/2014 Additional information available at www.ncnar.org Page 1 of 2
N.C. Department of
Health & Human Services
Division of Health Service
Regulation
Health Care Personnel Registry
FAX: (919) 733-3207
Phone: (919) 855-3968
2719 Mail Service Center
Raleigh, NC 27699-2719
5-WORKING DAY REPORT
Investigation Report from Facility/Provider
24-Hour Initial report sent to HCPR?
Yes
No
Date submitted:
Via: FAX Mail IRIS Other
The results of all investigations must be reported
within 5-working days of the initial notification.
[see NC Gen. Stat. §131E-256(g)]
Certain Nursing Facilities (NF), Skilled Nursing Facilities (SNF), Hospices provided in LTC
facilities, & Intermediate Care Facilities for the Mentally Retarded (ICF-MR) are required
to report a reasonable suspicion of a crime. [see Sec. 1150B.(42 U.S.C. 1320b-25)]
Provider Information
County:
Facility/
Provider Type:
Facility/Provider Name:
Facility/Provider
License #:
National
Provider #:
Other ID #:
Main Office
Phone #:
( )
Main Office
(Secure) Fax #:
( )
Administrator/
Director
Email Address:
Contact Person:
Mr. Ms.
Title:
Administrator:
Mr. Ms.
Title:
MAIN OFFICE
Mailing Address:
City:
State:
Zip:
ACTUAL INCIDENT
Location Address:
City:
State:
Zip:
Allegation/Incident Type
(check all that apply)
REASONABLE SUSPICION OF A CRIME
(Explain under “Allegation/Incident Details” below)
Is reasonable suspicion of a crime related to any
allegation checked below? Yes No
RESIDENT ABUSE
DIVERSION OF FACILITY DRUGS
(Estimated Value: )
MISAPPROPRIATION OF FACILITY PROPERTY
(Estimated Value: )
RESIDENT NEGLECT
FRAUD AGAINST RESIDENT
MISAPPROPRIATION OF RESIDENT PROPERTY
(Estimated Value: )
DIVERSION OF RESIDENT DRUGS
(Estimated Value: )
FRAUD AGAINST FACILITY
INJURY OF UNKNOWN SOURCE
(Explain under “Allegation/Incident Details” below)
Allegation/Incident Details
Incident Date:
Time:
a.m. p.m.
Incident location description:
Description of Incident:
Incident result in physical injury/ harm?
Yes
No
Mental anguish lasting 5 days or more?
Yes
No
Describe resident’s injury/ harm below (attach pictures):
Describe resident’s emotional response & behaviors below:
Accused Individual Information
Full Name:
Mr. Ms.
Job Title:
Date of Hire:
Date of Birth:
Social Security # (required):
Taxpayer ID #
or other ID #:
Last Known Address:
City:
State:
Zip:
Home Phone #:
( )
Other Phone # (Cell phone, work, etc.):
( )
E-mail address:
Other
information:
DHSR/HCPR Form No. 4500 Rev. 06/24/2014 Additional information available at www.ncnar.org Page 2 of 2
Resident Information
Resident
Full Name:
Mr. Ms.
Date of
Birth:
Resident Address if
different from Facility:
City:
State:
Zip:
Is Resident
Interviewable?
Yes
No
Memory & Orientation of Resident:
Resident’s Type of Care/ Service & Setting:
Additional resident information:
(Examples - Home Care, Nursing Home, Hospital/Acute Care, Day Program, CAP, CBS, Substance Abuse, Respite, etc.)
Actions
Allegation Substantiated?
Yes
No
Investigation End Date:
Facility/
Provider
Facility/ Provider
Investigator:
Mr. Ms.
Title:
Accused individual’s employment terminated?
Yes
No
Termination related to allegation?
Yes
No
Date of Termination:
Other employment actions:
Other information:
Social Services
Incident reported to County Dept. of Social Services (DSS)?
Yes
No
Date reported to DSS:
Name of County Dept of Social Services:
On-site visit by DSS?
Yes
No
Date of on-site visit:
Name of DSS Investigator:
Phone #
( )
Other information:
Law Enforcement
Is there a Reasonable Suspicion of a Crime?
Yes
No
Is there Serious Bodily Injury?
Yes
No
Incident reported to law enforcement?
Yes
No
Date reported:
Time
Reported:
Name of law enforcement agency:
Investigating Officer:
Phone #:
( )
Accused charged?
Yes
No
Charges related to allegation?
Yes
No
Specific Charges:
Other information:
Witness(es)
Witnesses to Incident?
Yes No
Number of Witnesses:
[Include any resident witnesses]
Name:
Mr. Ms.
Title:
Relationship to
Victim/Accused:
Address:
City:
State:
Zip:
Home Phone #:
( )
Other Phone (Cellular, Work, etc.):
( )
Name:
Mr. Ms.
Title:
Relationship to
Victim/Accused:
Address:
City:
State:
Zip:
Home Phone #:
( )
Other Phone (Cellular, Work, etc.):
( )
(LIST ADDITIONAL WITNESS NAMES & INFORMATION ON AN ATTACHED SHEET)
*Check the following supporting documents/information attached & submitted with this report*
Complete details of facility investigation
Witness, accused, & other statements
Documentation of injury/harm to victim
Other pertinent documents:
Reports from other agencies investigating incident
(Print Name and Title of Person Preparing Report)
(Signature of Person Preparing Report) (Date Signed)
