Report an incident regarding a health care facility
The Incident Reporting Form is only for facilities to notify the Indiana State Department of Health of an unusual occurence. This form is not to be used to file a complaint.
Contact
Phone: 317-233-5359
Fax: 317-233-7494
Form
Facility Incident Reporting Form
Please include the following information when submitting your incident report via email (or simply use the Word form above):
- Facility Name
- Facility Address
- Facility City, State and Zip
- Person making the report and their Title
- Date and Time of Incident
- Residents involved, Room #, Age and Diagnosis
- Staff involved and their Title (CNA/QMA must include the State Nurse Aide Registry Number)
- Brief Description of Incident
- Type of Injury/Injuries
- Immediate Action Taken
- Preventative Measures Taken
- Type of Report (choose one): Initial / Follow-up / Initial with Follow-up
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