Incident department licensing 2026

1. Click ‘Get Form’ to open the incident department licensing document in the editor.
2. Begin by entering the 'Date Received' and 'Date Reviewed' at the top of the form. Ensure you include your initials for verification.
3. Fill in the 'Name of Facility/Home' and 'License Number' fields accurately, as these are crucial for identification.
4. Provide details about the person directly involved in the incident, including their name, address, phone number, and relationship (Resident, Employee, Visitor).
5. In the 'Facts of the Incident' section, specify the date and time of the incident. Describe what happened and any injuries sustained.
6. Document actions taken by staff and any corrective measures implemented to prevent future occurrences.
7. Complete the notification section by listing all individuals or agencies notified about the incident along with dates and times.
8. Finally, ensure that both you and a licensee sign and date the report before submission.

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