Massachusetts Department of Public Health
Bureau of Substance Addiction Services / Office of Quality Assurance and Licensing
HEALTH AND SAFETY REQUIRED NOTIFICATIONS REPORTING FORM (105 CMR 164.035)
Please fax completed form (no cover sheet is necessary) to QAAL secure fax: 617-624-5395
Date of This Report:
Name/Title of Reporter:
Agency/Program Name:
Phone #:
Address: BSAS Lic/Appr #:
The Bureau of Substance Addiction Services requires all licensed and/or funded programs to notify
the Department immediately (24 hours) when serious events occur.
Please fill out the following form by checking the box that applies.
include any internal investigations/reports that the program has conducted,
; please submit as soon as possible. If the internal investigation/report is still
provide a timeline of when BSAS can expect the information.
Fire or other event resulting in damage to the program or interruption of services.
Condition at the program posing a threat to client health or safety (regardless of whether service is
interrupted/suspended).
Specify condition posing threat to health/safety: Loss of essential services, Limits on access to site,
Unsanitary conditions (e.g., bed bugs), Other (specify type):
Serious injury that occurred under program auspices, regardless of location. (Ex. Overdose)
Alleged abuse or neglect or physical or sexual assault:
Between/among clients and staff regardless of location Between or among clients at the program
Does the staff person hold a license or certification? Yes No
Elopement (only for adolescents).
Involuntary closure not due to an action by DPH/BSAS.
Confirmed case of communicable disease.
eport of
alleged to have occurred at program.
Report of elder abuse/neglect alleged to have occurred at program.
Report of abuse of a disabled person alleged to have occurred at program.
Civil action or criminal charge against program or employee(s) relating to delivery of service.
Other Event as per 164.035 (please specify):
If incident was reported to another agency
, please identify: DMH DPH/DHCQ DCF
ATTACH DESCRIPTION OF INCIDENT AND PROGRAM RESPONSE
(may attach
incident report filed with other age
ncy), including where incident occurred or was alleged to have
incident, date program learned of incident, and who filed the report.
Please do not scan or send client identifying information since email is not secure.
Revised: 1/18
Date(s) of birth of child or youth involved if applicable:
