Report a Medical Facility Incident

How to Report a Nursing Facility Incident

To report an incident, complete the Reportable Incident Form for Certified, Licensed or Registered Providers (PDF) and submit it to the Division of Licensing & Certification using one of the following options:

Option 1: Fax: (207) 287-9307 - Augusta District Office

Option 2: Mail:

  • Division of Licensing and Certification
  • 11 State House Station
  • 41 Anthony Avenue
  • Augusta Maine 04333

To promote consistency and save your staff some time, providers may want to pre-fill the form with the facility’s name, address, and other information that remains the same and save a copy of your pre-filled incident form for future use.

Alternatively, you may choose to report an incident online using the form below.

Option 3

Facility Information
Reporters Details
Type of Incident
Type of Incident
Residents/Patients Involved
Full Names, Unit, Room Number

Include any staff present at the time of the incident:

Full Names, Title/Relationship, Phone Number

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

Full Name, Title/Relationship, Phone, Employment Status

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?
Please describe in full below
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?
Describe in detail below:
Check any of the authorities below that have been notified.
Email (CC:) yourself or parent organization