Revised 4/08/2009
New Mexico Department of Health
DOH/DHI Use Only
This Form Will Not Be Submitted Until You Have Completed All The Required Fields On Each Page.
HEALTH FACILITY INCIDENT REPORT (SFY 2017)
Fields in red are required
Case #:
Name of
Consumer
First:
Middle:
Last:
Social
Security #
Gender
Male
Female
DOB:
Residence
Address
Street Address:
City:
Zip:
Phone:
Consumer Competency Level
ADLs (Resident Needs Assistance With) Check All That Apply
High
Moderate
Low
Walking
Wheelchair
Bathing
Eating
Transfer
Total Care
None
Verbal
Yes
No
Diagnosis(es):
Name of Consumer's Doctor:
Doctor's Phone:
TYPE OF ALLEGED INCIDENT
Abuse
Neglect
Exploitation
Injuries of Unknown Origin
Person responsible for individual's care at time of incident:
Name:
Title:
Phone:
Has this happened before?
YES
NO
Was anyone else present at the time of the incident?
YES
NO
If YES, Identify below:
Name:
Title or Relationship:
Phone:
Name:
Title or Relationship:
Phone:
Date Of Incident:
Time Of Incident:
AM
PM
Unknown
Describe what you saw and/or what you heard in order of occurrence:
Before the Incident:
During the Incident:
After the Incident:
Person Completing Sections 1 & 2
Confidentiality
Desired:
Name:
Agency:
Title/Relationship:
Phone:
Date
Completed:
Time
Completed:
YES
NO
This Form Will Not Be Submitted Until You Have Completed All The Required Fields On Each Page.