Yes No C. PHYSICAL RESTRAINTS AND SECLUSION 1. Did the resident die while in restraint or seclusion? 2. Did the restraint / seclusion have a direct relationship to the death? resident’s 3. Did the resident sustain any injury while in restraint or seclusion? Reason for Reporting Name Residential Case Manager Telephone Number – SIGNATURE Person Completing Form Date Signed – Title Person Completing Form Telephone Number – TO BE COMPLETED BY THE LICENSING SPECIALIST Name (Print) Telephone Number SIGNATURE Licensing Specialist Date this CFS-2183 is forwarded to DSP Child Welfare Program Specialist (mm/dd/yyyy) –
Yes No C. PHYSICAL RESTRAINTS AND SECLUSION 1. Did the resident die while in restraint or seclusion? 2. Did the restraint / seclusion have a direct relationship to the resident’s death? 3. Did the resident sustain any injury while in restraint or seclusion? Reason for Reporting Name – Residential Case Manager Telephone Number SIGNATURE – Person Completing Form Date Signed Title – Person Completing Form Telephone Number TO BE COMPLETED BY THE LICENSING SPECIALIST Name (Print) Telephone Number SIGNATURE – Licensing Specialist Date this CFS-2183 is forwarded to DSP Child Welfare Program Specialist (mm/dd/yyyy)
2183.docx