Reportable Incident Form

Reportable Incident Form for Certified, Licensed or Registered Providers

Complaint Line: 207-287-9308
Fax Line: 207-287-9307
Email: dlrs.complaint@maine.gov

Facility Information

Facility Name:

City/Town:

Facility in which the incident occurred is licensed as:

Name of Person Reporting the Incident:

Title:

Phone Number:

Email:

Type of Incident:


 

Date of Incident:

Time of Incident:

Residents/Patients Involved

List all residents/patients involved:

Full Names, Unit, Room Number

List all witnesses

Include any staff present at the time of the incident:

Full Names, Title/Relationship, Phone Number

List the people alleged to be involved in the incident, if applicable.

If staff members are listed, please indicate their status of employment, ex.; suspended/working/leave/etc.

Full Name, Title/Relationship, Phone, Employment Status

Description of Incident:

Please include how & why and if this incident has occurred before:

Assessment of the Resident/Patient

What was the resident/patient's mental and functional status at the time of the event?

Check any that apply.


What interventions were in place at the time of the incident?

Please describe in full below:

Extent of injuries and any treatment that was provided

Please describe in full below:

Were there any adverse effects to the resident/patient (physical or mental)?

Actions Taken by the Facility

Was the Physician notified?

Were the Family, Guardian, etc. notified?

Was resident transferred to a hospital?

Where were they transferred?

When were they transferred?

What was the outcome, if known (admitted, fracture, death, etc.)?

Have any new interventions or corrective actions been implemented?

Describe in detail below:

Check any of the authorities below that have been notified.





Email (CC:) yourself or parent organization: