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How to use or fill out PDF Nursing Facility Reported Incident (FRI) Form - State of Oregon
- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'What Alleged Violation are You Reporting' section. Select all applicable violations such as Mistreatment, Abuse, or Neglect.
- Provide facility information including today's date, facility name, CCN number, and contact details in the 'Facility Information' section.
- 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.
- 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.
- Complete the 'Reported Perpetrators' section by providing names and details of individuals involved. Ensure not to list residents as perpetrators.
- Finally, review all sections for accuracy before clicking ‘Submit’ to send your completed form via secure email.
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