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Section 1 - Resident/Patient/Client Information
Complete as much demographic information as possible. Name and or social security number is critical. If you do not have the Social Security Number then leave the field blank. The address is the physical address of the incident, not the address of the main corporate office.
Section 2 - Description of the Incident
Complete the allegation type.
Definitions of the incident type may be found in the program manual.
Complete the questions regarding responsibility and provider agency.
Complete the incident date and time.
Describe the incident: Give as much detailed information regarding before, during and after the incident.
Complete the bottom of this section and give a telephone number where you can be reached in the event that the case will be investigated.
Section 3 - Agency/Facility Information
Complete this section reporting the entire agency name. Initials maybe confusing as two or more providers may have the same initials. If you are a unit of a larger facility, please put the name of the unit/wing/house.
Section 4 - Administrative Information
Complete the appropriate funding source and all other information you may have available to you.
Section 5 - Notifications to Agencies
Document if you contacted the legal guardian or case manager and or other entities.
Before printing the report please set all your print margins to 0 (zero). In Internet Explorer this can be accomplished by going to “File”, “Page Setup” and then set all the print margins to 0 (zero) and click on “OK”. In Netscape go to “File”, “Page Setup”. Select the “Margins & Header/Footer” Tab and then set all the margins to 0 (zero) and click on “OK”. The same steps can also be used for Mozilla. In Opera go to “File”, “Print Options” and set all the print margins to 0 (zero) and click on “OK”. By changing the print margins it will ensure that the Incident Report Form will print correctly.
Please ensure that you print the online form for your records. The printed version will display a tracking number in the upper right hand corner. This tracking number is used by Health Facility Licensing and Certification staff to ensure the form was properly submitted. Questions about the use of the Online Incident Report Form can be directed to the Health Facility Bureau at 505-476-9025.

To ensure proper receipt of your Incident Report, please FAX a copy of your printed Online form with tracking number to 888-576-0012 in addition to submitting it online.