Fillable Health Care Professional Responsibility and Reporting Enhancement Act (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Health Care Professional Responsibility and Reporting Enhancement Act (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Health Care Professional Responsibility and
Reporting Enhancement Act Reporting Form
Health Care Entity Information
InitialReport Follow-uptoapreviouslyledreport
Health Care Entity Type:
HealthCareFacility Insurancecompanyofferingmanagedcareplans HMO
Stateorcountypsychiatrichospital Statedevelopmentalcenter Stafngregistry
Homecareservicesagency Assistedlivingresidenceorprogram
Comprehensivepersonalcarehome Licensedalternatefamilycaresponsoragency
Nonprothomemakerhomehealthaideagency
Nameofpersonsubmittingreport:_______________________________________________________________________________________
Titleorpositionofpersonsubmittingreport:_______________________________________________________________________________
Telephonenumber(includeareacode):___________________________ Faxnumber(includeareacode):___________________________
E-mailaddress:________________________________________________ DHSSfacilityID# (if applicable): __________________________
Healthcareentityname:_______________________________________ Healthcareentitylicensenumber:_________________________
Healthcareentitystreetaddress:_________________________________ City/ZIPcode:_______________ County:___________________
Nameandtelephonenumberofthosewhohaverst-handknowledgeofthereportableevent:
_____________________________________________________________________________________________________________________
Health Care Professional Information
Lastname:__________________________________________First: _______________________________Middle: _____________________
Typeofprofessionallicenseorcerticateheld:___________________________ Licenseorcerticatenumber:_______________________
Relationshipofthehealthcareprofessionaltothehealthcareentity(selectone):
employedby hasprivilegesgrantedby
undercontracttoprovideprofessionalservices providesservicesviaahealthcareservicermorviaastafngregistry
Additional Information (Please complete A & B)
A. Thereportableactionoreventtakenbythehealthcareentitywasrelatedtothehealthcareprofessional’s:
impairment
incompetencywhichrelatesadverselytopatientcareorsafety
professionalmisconductwhichrelatesadverselytopatientcareorsafety
B.Thereportableactionoreventtakenbythehealthcareentitywas:
Fullorpartialprivilegessummarilyortemporarilyrevokedorsuspended,orpermanentlyreduced,suspendedorrevoked.
Ifchecked,pleaseprovidedetailsofhealthcareentity’saction:
Removedfromthelistofeligibleemployeesofahealthservicesrmorstafngregistry
Dischargedfromthestaff
Contracttorenderprofessionalservicesterminatedorrescinded
Conditions or limitations placed on the exercise of clinical privileges or practice within the health care entity (including, but
not limited to second opinion requirements, non-routineconcurrent or retrospective review of admissionsor care, non-routine
supervisionbyoneormoremembersofthestaff,completionofremedialeducationortraining)
____________________________________________________________________________________________________________
or
Voluntaryresignationofhealthcareprofessionalfromstaffif:
Thehealthcareentityisreviewingthehealthcareprofessional’spatientcareorreviewingwhether,baseduponitsreasonable
belief, the health care professional’s conduct demonstrates an impairment or incompetence or is unprofessional, which
incompetenceorunprofessionalconductrelatesadverselytopatientsafety.
Thehealthcareentity,throughanymemberofthemedicaloradministrativestaff,hasexpressedanintentiontodosuchareview.
or
Voluntaryrelinquishmentbyhealthcareprofessionalofanypartialprivilegesorauthorizationtoperformaspecicprocedureif:
Thehealthcareentityisreviewingthehealthcareprofessional’spatientcareorreviewingwhether,baseduponitsreasonable
belief, the health care professional’s conduct demonstrates an impairment or incompetence or is unprofessional, which
incompetenceorunprofessionalconductrelatesadverselytopatientsafety.
Thehealthcareentity,throughanymemberofthemedicaloradministrativestaffhasexpressedanintentiontodosuchareview.
or
LeaveofAbsencegrantedtothehealthcareprofessional,whileunder,orsubsequenttoareviewofthehealthcareprofessional’s
patientcareorprofessionalconduct,forreasonsrelatingtoaphysical,mentaloremotionalconditionordrugoralcoholusewhich
impairsthehealthcareprofessional’sabilitytopracticewithreasonableskillandsafetyexceptforpregnancyandrelatedleavesor
documentedparticipationinanapprovedprofessionalassistanceorinterventionprogram.
or
Medicalmalpracticeliabilitysuitresultinginasettlement,judgmentorarbitrationaward,inwhichboththehealthcareprofessional
andhealthcareentityareparties
or
ProfessionalAssistanceProgramorInterventionProgram
Health care professional has failed to comply with a request to seek assistance from a professional assistance or
interventionprogram
Health care professional has failed to follow the treatment or monitoring program required bya professional assistance or
interventionprogram
or
Follow-uptoapreviouslyledreport
Healthcareprofessional,whohasbeenthesubjectofapreviousreport,hashadconditionsorlimitationsontheexerciseofclinical
privilegesorpracticewithinthehealthcareentityaltered,orprivilegesrestored,orhasresumedexercisingclinicalprivilegesthat
hadbeenvoluntarilyrelinquished
2. Dateofthereportableactionoreventtakenbythehealthcarefacility:__________________________________
3. Dateofthehealthcareprofessional’sconduct: _________________________________
4. Detailsofthehealthcareprofessional’sconduct:
Signatureofpersonsubmittingreport:_______________________________________________ Dateofreport:_____________________
Hasacopyofthisreporthasbeenprovidedtothehealthcareprofessionalwhoisthesubjectofthisreport?
Yes No
Hasacopyofthisreporthasbeenprovidedtothehealthcareservicermorstafngagencywithwhichthehealthcareprofessionalis
employed?
Yes No
NotApplicable
Reports are to be submitted within seven (7) days of reportable action or event to
Francine Widrich, Clearinghouse Coordinator
New Jersey Division of Consumer Affairs
via fax at 973-792-4270 or
via email at widrichf@dca.njoag.gov
For information, please call 973-504-6310 or 973-896-8058.
For Ofce Use Only
Case number: DCA ____________________________
(To be assigned by the Division of Consumer Affairs)
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Health Care Professional Responsibility and Reporting Enhancement Act (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 21 July 2020

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