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Facility Self-Reporting

A licensed facility may utilize the forms contained on this webpage to submit information regarding a reportable incident or utilize their own form for reporting a reportable incident. When utilizing any other form than the forms contained on this webpage, please email to or fax to 402-471-1679.

The forms are made available as an interactive document. Thus they can be completed on screen by using the mouse to click on a particular field or by using the Tab key to move from field to field. (Use Shift - Tab to move backwards in the form.)

The completed form can be submitted by clicking on the submit button, the email address listed on the form will receive an emailed copy of the report for your records.

All forms will have some mandatory items indicated by a red asterisk (*).

If you have any supporting documentation please email to or fax to 402-471-1679.

Nursing Home Facility Reporting Requirement Memo (The links in the memo in Item D access report forms that need to be submitted via mail or fax.)

To submit forms electronically, click on the form name below that you want to submit.

Injury of Unknown Origin Form
Misappropriation Form
Neglect Form  
Physical Abuse Form
Sexual Abuse Form
Verbal Abuse Form

For more information, Contact: 

Program Manager, Office of Long Term Care Facilities 
Phone: (402) 471-3324

Other Contacts

Medication Aide Registry
Phone: (402) 471-4364

Nursing Assistant Registry
Phone: (402) 471-4971
Long-Term Care Ombudsman
Phone: (402) 471-2307

Adult Protective Services
Phone: 1-800-652-1999

Medicare Fraud Hotline
Phone: 1-800-Medicare 1-800-Medicare

Attorney General’s Office (billing and/or financial complaints)
Phone: 402-471-2682

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