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Dialysis Center Self-Reported Event Form

Please select the download button to view "dialysis center self-reported event form."

IMPORTANT: THIS FORM MUST BE DOWNLOADED TO A PC, COMPLETED, AND E-MAILED AS AN ATTACHMENT TO COMMUNITY@ODH.OHIO.GOV.  THIS FORM IS UNABLE TO BE SENT THROUGH AN INTERNET BROWSER.  ATTEMPTING TO DO SO COULD RESULT IN A LOSS OF TYPED INFORMATION.