Initial Allegation of Mistreatment, Abuse, Neglect, or Theft and Facility Reported Incidents Reporting Form

Facilities please use this form to report an incident. Once the form is submitted there will be a PDF copy for you to print.

Facility Information

Please provide the information below. If you don't see the name of the facility in the drop-down, please select Unlisted and add the name of the facility in the Other Name text box.


Facility Name	Other Name	Phone Number
Caller's Name	Email address for feedback from department

Registry Information

Please provide information for the Registrant you are investigating.


Registrant Name	Registry Number	Last 4 of SSN


	Please check the box if the Registrant is not on the the ND nurse aid registry.

Incident Information

Please provide information regarding the incident below.


Date of the allegation (incident)	Time of the allegation (include AM or PM)
Resident Full Name (Include First and Last Name)	Resident Room Number

Name of witness(es)

Briefly describe the alleged incident and/or injury

How do you plan to protect all residents during the time you are investigating this allegation?


Was local law enforcement notified?	Yes	No
Law Enforcement Type

Please Note: A final investigation report is due within 5 working days.


Was the Resident Injured?	Yes	No
Injury Type	Minimal
	Moderate
	Severe