Printable blank New York Incident Report Form DSS-3123

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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.

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