Mandatory Reporting Form

Your Name

Phone Number

Facility Name

INITIAL 24 HOUR REPORT

Date of your initial report to the State Agency

Date of the allegation/injury

Time of the allegation/injury

Name of the Resident(s)

Name of the victim (residents)

Name of the aggressor(s)

Brief description of the allegation/injury

Was medical treatment necessary and if so what

The plan to prevent further abuse

Date results sent to the State Agency

Your Name(s)

Outcome of your investigation