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.

Registry Information

Please provide information for the Registrant you are investigating.

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.

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