Bureau of Human Services Licensing
Incident Reporting Form
Type of Report: Initial Final Initial/Final
Facility Information
Regulatory Chapter
Name of Legal Entity:
Name of licensed setting
as it appears on license:
Facility Address:
License Number: Phone Number:
Incident Information
Date Of Incident:
Time of Incident:
Regulation # and type of
Date Incident reported to Department:
Time Incident reported to Department:
Resident Information
Complete for any incident relating to a specific resident(s)
Name (Last, First)
Date of Birth
Name (Last, First)
Job Title
Description of Incident
(Attach Additional Pages as Necessary) Please provide as much detail as possible about the incident, including what happened,
where it happened, when it happened, the licensed setting’s response, etc.
Follow-Up Action Taken
What action, if any, was initiated or is planned in response to the incident? Include any contacts made.
Contact Information
Name of person completing report: Title:
Contact Person Name: Telephone Number: