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DEATH OR SERIOUS INJURY REPORT FAX TRANSMISSION COVER SHEET DATE: NUMBER OF PAGES: (including this cover sheet) DESTINATION INFORMATION: Department of Human Services Licensing Division PO Box 64242,

How to fill out death or serious injury

How to fill out MN Death or Serious Injury Report Fax

1. Obtain the MN Death or Serious Injury Report Fax form from the Minnesota Department of Health website or your local office.
2. Fill in the required details including the name of the deceased or injured person, date of incident, and your contact information.
3. Provide all pertinent details about the incident, including location, time, and circumstances surrounding the death or injury.
4. Include any necessary supporting documentation if required.
5. Review the completed form to ensure all information is accurate and complete.
6. Fax the completed report to the appropriate number provided on the form.

Who needs MN Death or Serious Injury Report Fax?

1. Healthcare providers and facilities that experience a death or serious injury.
2. Organizations and agencies that are required to report incidents for compliance or regulatory purposes.
3. Local law enforcement or medical examiners investigating the incident.

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What is MN Death or Serious Injury Report Fax?

The MN Death or Serious Injury Report Fax is a formal notification required by the Minnesota Department of Human Services (DHS) that is submitted when a death or serious injury occurs in a facility regulated by the DHS.

Who is required to file MN Death or Serious Injury Report Fax?

Providers of services that are licensed or registered by the Minnesota Department of Human Services, such as group homes and care facilities, are required to file the MN Death or Serious Injury Report Fax.

How to fill out MN Death or Serious Injury Report Fax?

To fill out the MN Death or Serious Injury Report Fax, the provider must complete the required sections accurately, providing details such as the individual's information, the incident date, a description of the death or injury, and any immediate actions taken.

What is the purpose of MN Death or Serious Injury Report Fax?

The purpose of the MN Death or Serious Injury Report Fax is to ensure that the Minnesota Department of Human Services is informed of significant incidents that may impact the health and safety of individuals receiving services.

What information must be reported on MN Death or Serious Injury Report Fax?

The report must include essential information such as the name of the individual involved, the nature of the incident, the date and time it occurred, the location, any actions taken, and the reporting person's details.