OCFS-LDSS-7005 (5/2014) REVERSE OFFICE OF CHILDREN AND FAMILY SERVICES medication error report FORM Describe the Incident (Include all individuals involved in the ACTION TAKEN OCFS NOTIFIED VERBALLY: DATE NOTIFIED (mm/dd/yy): TIME(AM/PM): PERSON NOTIFIED: Yes No / / FORM SUBMITTED TO OCFS: DATE NOTIFIED (mm/dd/yy): PERSON NOTIFIED: Yes No / / PARENT NOTIFIED (Required Immediately): DATE NOTIFIED (mm/dd/yy): TIME(AM/PM): PERSON NOTIFIED: Yes No / / OTHER PERSONS NOTIFIED DATE NOTIFIED (mm/dd/yy): PERSON(S) NOTIFIED: (Ex. Health Care Provider, Health Care / / Consultant): Yes No Describe Corrective Action: NAME OF PERSON COMPLETING THIS FORM: (Please Print): DATE FORM COMPLETED: SIGNATURE OF PERSON COMPLETING THIS FORM: X
OCFS-LDSS-7005 (5/2014) REVERSE OFFICE OF CHILDREN AND FAMILY SERVICES medication error report FORM Describe the Incident (Include all individuals involved in the ACTION TAKEN OCFS NOTIFIED VERBALLY: Yes No DATE NOTIFIED (mm/dd/yy): / / TIME(AM/PM): PERSON NOTIFIED: FORM SUBMITTED TO OCFS: Yes No DATE NOTIFIED (mm/dd/yy): / / PERSON NOTIFIED: PARENT NOTIFIED (Required Immediately): Yes No DATE NOTIFIED (mm/dd/yy): / / TIME(AM/PM): PERSON NOTIFIED: OTHER PERSONS NOTIFIED (Ex. Health Care Provider, Health Care Consultant): Yes No DATE NOTIFIED (mm/dd/yy): / / PERSON(S) NOTIFIED: Describe Corrective Action: NAME OF PERSON COMPLETING THIS FORM: (Please Print): DATE FORM COMPLETED: SIGNATURE OF PERSON COMPLETING THIS FORM: X
OCFS-LDSS-7005.docx