ICF Out of or Return to Facility Notification Form
This form is used for any time that an individual from the ICF is leaving facility for ER visit, are admitted to hospital, extended leave of absence, or when returning to facility from the above.
Individual Name
*
First Name
Last Name
Facility location:
*
Park West
Johnstown
Type of Notification (select choice):
*
Out to ER
Hospital Transfer
Hospital Admission
Hospice Admission (Home or Hospital)
Hospital Discharge
Hospice Discharge
LOA Out of Facitily- Visiting Friends and/or Family
LOA Out of Facility- Visiting potential new residence
LOA Out of facility- Vacations (24 hours or more)
LOA Out of Facility-All other reasons
LOA Return to Facility
Facility Discharge (Including Deaths)
ER Discharge
Respite Discharge
Hospital Name
*
Hospice Provider Name
*
Date
*
-
Month
-
Day
Year
Date
Time (left facility)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time (of admission)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time (arrived back to facility)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Reason for ER/ LOA visit:
*
Diagnosis:
*
Was individual tested for COVID-19?
Yes
No
COVID-19 test result:
Positive
Negative
Other supplemental information:
Upload hospital admission/discharge paperwork and other documents here:
Browse Files
Cancel
of
Upload any pertinent documents here:
Browse Files
Cancel
of
Upload hospice admission/discharge paperwork and other documents here:
Browse Files
Cancel
of
Upload hospital transfer paperwork and other documents here:
Browse Files
Cancel
of
Name of Personnel or Nurse completing form:
*
First Name
Last Name
Email of Personnel or Nurse completing form:
*
example@example.com
Submit
Should be Empty: