AUTHORITY The following rules and regulations for the - Arkansas ...
AUTHORITY The following rules and regulations for the - Arkansas ...
AUTHORITY The following rules and regulations for the - Arkansas ...
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Facility Investigation Report <strong>for</strong> Resident Abuse, Neglect, Misappropriation of Property,<br />
& Exploitation of Residents in Long Term Care Facilities<br />
OLTC Witness Statement Form<br />
Date: Time: AM/ PM<br />
Witness Full Name:<br />
Job Title:<br />
Home Address:<br />
City/Zip<br />
Shift:<br />
Home Phone #: Work Phone #:<br />
Relation to Resident (If Any?)<br />
State in your own words what you witnessed (be very descriptive) <strong>and</strong> sign below.<br />
(Continue on Back as Necessary)<br />
<strong>The</strong> in<strong>for</strong>mation provided above is true to <strong>the</strong> best of my knowledge:<br />
Signature of Witness:<br />
Date:<br />
39<br />
Residential Care Facilities R. 08/01/07