DDS Death Reporting Form Instructions

1.	Individual’s First Name:  Fill in first name of person whose death is being reported.
2.	Individual’s Last Name:  Fill in last name of person whose death is being reported.
3.	SSN:  Fill in the Social Security number of person who died.
4.	Date of Birth:  Fill in date of birth of person who died, using format MM/DD/YYYY.
5.	Age:  Fill in age of person who died.
6.	Address Line 1:  Fill in street address of person who died.
7.	Address Line 2:  Fill in additional address information like apartment number, if applicable
8.	City: Fill in name of city where person lived.
9.	State:  Fill in state where person lived.
10.	Zip Code:  Fill in zip code where person lived.
11.	Phone Number:  Fill in home phone number for person.
12.	Region:  Check off the DDS/MRC Region that person lived in. 
13.	Area Office/Facility:  Select name of Area Office or Facility of person (See Dictionary #1).  If person was on ABI/MFP waiver, check off “N/A (If ABI/MFP)”. The first “Choose an item” area lists the Area Offices; the second “Choose an item” area lists the facilities.
14A.  Waiver Program Enrollment:  Select name of the waiver person was on (See Dictionary #2). If person was not on a waiver, select “Non-Waiver”.
14B. Class Status:  Check off the person’s class status.
Note: There is no box for Hutchinson. 
15.	Guardianship:  If the person has a guardian, fill in person’s guardian’s name and full address.
16.	Level of Intellectual Disability:  Check off the level of intellectual disability for the person:  mild, moderate, severe, profound or N/A.
17A. Down Syndrome:  Check off yes, no or unknown to whether or not the person had Down’s
      Syndrome.
17B. Acquired Brain Injury:  Check off “yes” if on the ABI waiver or if the person had an ABI and was on the MFP waiver. Check off “no” if the person was on an MFP waiver and did not have an ABI. Check off N/A if person was not on an ABI/MFP waiver, even if the person had an ABI. Check off “Unknown” if person was on the MFP waiver and ABI status was not known.
18.	Individual’s Case Manager/Service Coordinator:  Fill in name of person’s case manager/service coordinator.
19.	Primary Care Practitioner First Name:  Fill in first name of Primary Care Practitioner.
20.	PCP Last Name:  Fill in last name of Primary Care Practitioner.
21.	PCP Phone Number:  Fill in phone number for Primary Care Practitioner.
22.	Date of Death:  Fill in date person died, using format MM/DD/YYYY.
23.	Time of Death:  Fill in time person died using format HH:MM AM/PM.
24.	Type of Location of Death:  Select location of death. (See Dictionary #3.)
25.	If Death was at an Acute Care Hospital, Name of Hospital:  Fill in name of hospital where person died. If death was not at an acute care hospital, leave blank.
26.	Actual Name of Location of Death:  Fill in name of place where person died.
27.	Address Line 1:  Fill in street address of place where person died.
28.	Address Line 2:  Fill in additional address information for where person died if applicable.
29.	City:  Fill in city where place person died is located.
30.	State:  Fill in state where place person died is located.
31.	Zip Code:  Fill in zip code of place where person died.
32.	Phone Number:  Fill in phone number to place where person died.
33.	Reporter’s First Name:  Fill in first name of person completing death report.
34.	Reporter’s Last Name:  Fill in last name of person completing death report.
35.	Reporter’s Title:  Fill in title of person completing death report.
36. Reporter’s Area Office/Facility:  Select name of Area Office or Facility of person (See Dictionary #1). If person was on ABI/MFP waiver, answer N/A.  The first “Choose an item” area lists the Area Offices; the second “Choose an item” area lists the facilities.
37.	Reporter’s Phone Number:  Fill in phone number of person completing report.
38.	Date of Report:  Fill in date death report was completed using format MM/DD/YYYY.
39.	Presumed Cause of Death at Time of Death:  Select cause of death (See Dictionary #4). The first “Choose an item” area includes Cancer diagnoses; the second “Choose an item” area includes other diagnosis. Select the appropriate cause of death. Note:  Dictionary #4 is divided between the two “Choose an item” areas. You only need to select the cause from one “Choose an item” area.  Both areas do not have to be completed.
40.	If “Other” Presumed Cause of Death, Please Describe:  Fill in information about diagnosis at time of death if none of the options in Dictionary #2 applies.
41.	Circumstances of Death:  Write description of what happened in time just before death, as well as, circumstances surrounding the death. Include the source of the information.
42.	Did the Person have a Level II or Level III Behavior Modification Plan:  Check off “Yes” or “No” or “Unknown”.
43.	Was the person being restrained or in Time Out at, or  just Prior to, Death?:  Check off “Yes” or “No” or “Unknown”.
44.	Was a DNR in place?   Check off “Yes” or “No” or “Unknown” to whether a DO NOT RESUSCITATE order was written at the time of death

45A. At Time of Death, receiving Hospice Services?:  Check off “Yes” or “No” or “Unknown” to whether the person was receiving Hospice at the time of death
45B. Services Received on the Date of Death (From Meditech): List all service enrollments from  
       Meditech.
46A. Is a Mortality Review Required?: Check off “Yes” or “No”.
46B. If not required, is a Mortality Review requested?:  Check off “Yes” or “No” or “Unknown”.  
46C. If Requested, Reason for the Request:  Fill in reason why a Mortality Review was requested even though one is not required
47A. Was an autopsy requested?:   Check off “Yes” or “No” or “Unknown”.  
47B. Was an autopsy completed?: Check off “Yes” or “No” or “Unknown”.  
48A. Alert your Service Coordinator Supervisor/Program Coordinator and the Area Office/Regional designee when you click save?: Check off “Yes” or “No” or “Unknown”.  
48B. Was the Senior Investigator (or Regional on-call person, if after hours) Notified by Phone 
       Immediately?:  Answer “Yes” or “No”.
49.	Was DPPC Notified Immediately by Phone?:  Answer “Yes” or “No”.
50.	Date of DPPC Notification:  Fill in date DPPC was notified using format MM/DD/YYYY.
51.	Time of DPPC Notification:  Fill in time DPPC was notified using format HH:MM AM/PM.
52.	Was guardian or next of kin notified of the death?  Check off “Yes” or “No” or “Unknown”.  
53.	Was the Death under Suspicious Circumstances?:  Check off “Yes” or “No” or “Unknown”.  
54.	Were there any Indications of Violence (including sexual abuse)?:  Check off “Yes” or “No” or “Unknown”.  
55.	Were the State/Local Police Notified Immediately?:  Check off “Yes” or “No” or “Unknown”.  If answer to #54 is “Yes”, must  notify.
56.	Was the Medical Examiner’s Office Notified?:  Check off “Yes” or “No” or “Unknown”.  If answer to #54 is “Yes”, must be  notified.
57.	If Medical Examiner’s Office was Notified, did it take Jurisdiction?:  Check off “Yes” or “No” or “Unknown”.  Only answer if Answer to #56 is “Yes”.
58.	If the Individual was over 60 years old and if there are Indications of Violence, was EOEA Notified Immediately by Phone?:  Check off “Yes” or “No” or “Unknown”.  
59.	Date of EOEA Notification:  Fill in date EOEA was notified if answer to #58 is “Yes”.  Use format MM/DD/YYYY.
60.	Time of EOEA Notification:  Fill in time EOEA was notified if answer to #58 is “Yes”. Use format HH:MM  AM/PM.
61.	Finalized By:  Fill in the name of the person who assures the accuracy of the death report before it is submitted to Central Office.
62.	Finalized DATE:  Fill in date the death report was finalized using format MM/DD/YYYY.
FOR DDS INDIVIDUALS (INCLUDING ABI-RES HAB AND MFP-RS), ONCE SECTIONS 1-62 ARE COMPLETED THE DEATH REPORT MUST BE SUBMITTED ELECTRONICALLY (E_MAIL) TO DDS CENTRAL OFFICE INVESTIGATIONS .
FOR MRC INDIVIDUALS (ABI-N AND MFP-CL ONLY), ONCE SECTIONS 1-62 ARE COMPLETED THE DEATH REPORT MUST BE SUBMITTED ELECTRONICALLY (E_MAIL) TO MRC CENTRAL OFFICE.

63.	Is the Death Report Accepted?:  Investigations at Central Office checks off “Yes”, “No” or “Unknown”.
64.	If Not, Why Not?:  Fill out why Death Report has not been accepted by Central Office Investigations if answer to #61 is “No”.
65.	Finalized By:  Fill in the name of the person in Investigations who conducts the initial review.
66.	Finalized DATE:  Fill in date the death report was finalized by Investigations using format MM/DD/YYYY.
67.	Is the Death Report Accepted?:  Operations at Central Office checks off “Yes” or “No”.
68.	 Final Cause of Death (Primary):  Select the immediate cause of death (See Dictionary #4). The first “Choose an item” area includes Cancer diagnoses; the second “Choose an item” area includes other diagnosis. Select the appropriate cause of death
69.	Underlying Cause of Death (Secondary):  Fill in underlying cause of death (if any) (See Dictionary #5).
70.	If other to #68 or #69, Please Describe:  Fill in information about the cause of death.
71.	Manner of Death:  Fill in manner of death. 
72.	Was the Regional Clinical Mortality Review Received  at the Regional Level?  Answer “Yes” or “No” or “Unknown.”
73.	If yes, date received: Fill in date received, using format MM/DD/YYYY.
74.	Finalized by: Fill in the name of the person in Central Office who finalizes death report.
75.	Finalized Date: Fill in date the death report was finalized by Investigations using format MM/DD/YYYY.