Printable blank New York Incident Report Form DSS-3123

Fill Out Form
  • Edit
  • Fill out
  • Sign
  • Export

1. What I need the DSS-3123 for?

DSS-3123 is a free form that is used for reporting an incident that happened on or off the facility grounds. For example:

  • Residents were missing for more than 24 hours;
  • To report about resident abuse;
  • Death of the resid

2. What is a DSS-3123 form?

  • Fillable DOH-5175 form, also known as DSS-3123, is an New-York Adult Care Facility incident report form that consists of three pages of possible incidents, their description, and other fieldent;
  • A felony that was committed by or against the resident;
  • Residents assaulted or were assaulted by someone;
  • The behavior of the resident affected the well-being of the facility and other residents;
  • Resident was involved in an accident that required medical attention.

3. How to fill out DSS-3123?

You need to download DSS-3123 and then start pasting the required information, such as facility name, county, date of incident, time, resident name, and resident level of care.

You will have to mark the incident that has happened, describe it, tell more about the actions that were taken immediately, mention the location of the facility and the individuals that provided care. The description of current status of individuals involved is also necessary. Resident may also add the description of the accident.

Addendum to incident report of resident death or attempt of suicide is included. There you should fill the resident name, resident age, death cause, and the location of death.

4. Organizations that work with DSS-3123

  • Adult care facility services.

Relevant categories

Hear What PDFLiner Users Have to Say & Join Them Today

  • Fred Walters
    Entrepreneur
    Now that I’ve switched from Word to PDFLiner, I save lots of time processing and digitally distributing tons of billing forms, work orders, forecast reports, and invoices. In addition to this, thanks to PDFLiner, we’ve significantly minimized our paper consumption. Excellent tool that helps me cope with my business workflow faster and easier.
  • Peter Scheffel
    Self-employed attorney
    PDFLiner allows me to streamline the processes of generating and managing legal documents, as well as collecting electronic signatures for all my contracts and agreements. I like that I can customize forms on the go and access PDFLiner from all my gadgets. No more printing or scanning! That’s just brilliant!
  • Lisa Matthews
    University student
    When you’re a student, you deal with PDFs a lot… Newsletters, various worksheets, official forms you need to fill in and sign, etc… To me, filling out a PDF form used to be among the trickiest and most time-consuming things ever. But then a friend of mine introduced me to PDFLiner, and oh my God, my life has changed since then. It’s easy to use and has so many great features. Just awesome, I love it!
Please, wait...