ER Visit Reporting

ER Visit Reporting
Who is reporting?*

Direct Care Worker (DCW).Participant/ Member.
Direct Care worker's Name:*

First NameLast Name
Caregiver's Phone Number
Please enter a valid phone number.
Participant's Name*

First NameLast Name
Participant's Phone Number
Please enter a valid phone number.
Did the participant visit ER IN LAST 90 days.*

YESNO
Did you visit ER IN LAST 90 days.*

YESNO
Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for ER visit:*
Date & Time of the ER visit?*

MonthDayYear
Date
Hour MinutesAM/PM Option
Was the ER visit during the service hours? OR (Was After or before duty time?)*

YESNO
Who took the patient to the ER? (eg: Family member, Ambulance, Other)*
Is this incident happened due to accident? If so mention below. (Otherwise skip this)*

YESNO
Mention if any injuries, (eg: To any body parts: swelling, fracture etc)
I confirm that Participant named above did not visit to ER in last 90 days.
I confirm that I did not visit to ER in last 90 days.
Discharge Date and time: (Leave this field if not yet discharged)

MonthDayYear
Date
Hour MinutesAM/PM Option
Caregiver's Signature*

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Participant's Signature*

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Should be Empty: