PDF Nursing Facility Reported Incident (FRI) Form - State of Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'What Alleged Violation are You Reporting' section. Select all applicable violations such as Mistreatment, Abuse, or Neglect.
3. Provide facility information including today's date, facility name, CCN number, and contact details in the 'Facility Information' section.
4. In the 'Incident Details' section, specify the incident date and time, location, and provide a detailed description of the incident along with immediate measures taken.
5. List all residents involved in the incident. For each resident, include their name, Medicaid status, gender, date of birth, relevant diagnosis, and any outcomes related to the incident.
6. Complete the 'Reported Perpetrators' section by providing names and details of individuals involved. Ensure not to list residents as perpetrators.
7. Finally, review all sections for accuracy before clicking ‘Submit’ to send your completed form via secure email.

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