This government document is issued by Human Services for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:yqjcmted-sw&q=https://www.dhs.pa.gov/Licensing/BHSL-Licensing/Documents/Assited_Living-Reportable_Incident_Form_Effective_October_1_2016.pdf&sa=U&ved=2ahUKEwjqr6WC9PCFAxUw_7sIHXw_DG04HhAWegQIBBAB&usg=AOvVaw3Sr6riwfvVRfSj1TeFtqNE&arm=e