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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 dhhs.healthfacilityinvestigations@nebraska.gov 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 dhhs.healthfacilityinvestigations@nebraska.gov or fax to 402-471-1679.

Nursing Facility Reporting Requirement Memo (please disregard item D in the memo and use the forms listed below)

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:
Eve Lewis, Program Manager
Phone: (402) 471-3324
eve.lewis@nebraska.gov

Dan Taylor, Training Coordinator
Phone: (402)471-0535
daniel.taylor@nebraska.gov

Carrie Erickson, Staff Assistant
Phone: (402) 471-1719
carrie.erickson@nebraska.gov

Other Contacts

Medication Aide Registry

Sherri Joyner
Phone: (402) 471-4364
sherri.joyner@nebraska.gov

Nursing Assistant Registry

Nancy Stava
Phone: (402) 471-4971
nancy.stava@nebraska.gov

Long-Term Care Ombudsman

Patty Pierson
Phone: (402) 471-2307
patty.pierson@nebraska.gov

Adult Protective Services 1-800-652-1999

Medicare Fraud Hotline 1-800-Medicare

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

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