Community Behavioral Health Services - San Francisco Department ...

Children QOC FormCITY AND COUNTY OF SAN FRANCISCO COMMUNITY BEHAVIORAL SERVICES- CHILD, YOUTH & FAMILY SYSTEM OF CAREQUALITY OF CARE REPORTPrivileged And Confidential InformationThis form is for the exclusive use of Quality Management (Evidence Code 1157.6, W& I Code 4070 and 4071)Event is:π Quality of Care Occurrence (Requiresπ Other Quality of Care ConcernPlease check one Report within 24-Hours)See reverse side of form for definitions of categories.1a1b1c1d2a2b3a3b4a4b5678a8b910a10b111213Client Name: BIS #:Address: DOB: Sex: Phone #:EVENT Date: Location of event (program name & address)Describe the Quality of Care event in detail including client or staff directly involved:Corrective Actions Taken (recommendations and actions taken to prevent future occurrences:Printed name, signature, date, discipline, title or person completing report:Printed name, signature, date, discipline, title of charge/supervisor:CMHS CYF 102 2/02• Please fax report immediately to 415-252-3033 (which is secured and protected), and mail original Quality ofCare Report to Miriam Damon, 1380 Howard St. 5 th Floor, San Francisco 94103 by next business day.• A copy of this report should not be included in the client’s clinical/medical record.102