Massachusetts Department of Public Health
Bureau of Substance Addiction Services
REPORT OF DEATH OF PERSON IN TREATMENT
Please FAX completed form to:
BSAS / Office of Quality Assurance and Licensing
Fax #: 617-624-5395
105 CMR 164.000: Licensure of Substance Abuse Treatment Programs, specifically 164.035(G)(1),
requires licensed programs and/or funded programs to notify the Department in writing within
one
business day of learning of the death of any person currently admitted to the program, regardless
of
where the death occurs.
Date of this Report: Date of Death (if known):
Date Last Seen at Program: Date Program Learned of Death:
Name/Title of Reporter:
Follow Up Contact Person:
Progr
am Name & License #:
Program Phone #: Level of Care:
Program Address:
Client Name:
Client Admission Date: Date of Birth:
Client Gender: Female Male Transgender
Did the Death Occur on Program Site? Yes No If No, Where (if known):
Reason for Death (if known):
Describe any reports made to program and by whom:
Any information made available through media sources:
Comments:
For OTPs & OBOTs:
Medication: _____________________
Amount: _________mg
Date of Last Dose OR Last Prescription: ___________
(Revised 1/18)
