Alternative Required Healthcare Facility Event Reporting


Session Time Remaining 

Report Type
This form is intended to be used as an initial report by a healthcare facility staff member who has no facility login to the online event reporting page. This form is not intended for use by the public.
Facility
Patient/Resident Information
Event Reporting
Is the individual capable of providing an explanation of the event or capable of participating in investigation?
Allegation involved facility personnel?
Notifications
Law Enforcement Notification
Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.
Law Enforcement Notified?
Department of Human Services (DHS) Notification
Notify Dakota At Home (1-833-663-9673) only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.
DHS (not the Ombudsman)? APS worker notified?
Health Department Notification
Investigation Conclusion
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