Office of Administration Bureau of Human Services 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the type of report you are submitting: Initial, Final, or Initial/Final. Check the appropriate box.
3. Fill in the Facility Information section. Enter the Name of Legal Entity and the Name of licensed setting as it appears on the license. Provide the Facility Address and License Number, along with a contact Phone Number.
4. In the Incident Information section, input the Date and Time of Incident (AM/PM) and when it was reported to the Department.
5. Complete the Resident Information section by noting the Regulation # and type of incident, as well as the Time Incident was reported to Department (AM/PM).
6. For Persons Involved, list names (Last, First) and Date of Birth for any residents involved. Include details for staff or officers responding to the incident.
7. In the Description of Incident field, provide a detailed account including what happened, where it occurred, when it happened, and how your facility responded. Attach additional pages if necessary.
8. Outline any Follow-Up Action Taken in response to the incident. Include contacts made if applicable.
9. Finally, complete Contact Information by entering your name, title, contact person’s name, and telephone number.

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