Alternative Required Healthcare Facility Event Reporting

Report Type
This form is only to be used for submitting a report of type initial. It will be submitted as an initial report.
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
Upload File
Click here for recommendations on uploading files.