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 email@example.com 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 firstname.lastname@example.org 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
Physical Abuse Form
Sexual Abuse Form
Verbal Abuse Form
For more information, Contact:
Eve Lewis, Program Manager
Phone: (402) 471-3324
Dan Taylor, Training Coordinator
Carrie Erickson, Staff Assistant
Phone: (402) 471-1719
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 1-800-652-1999
Medicare Fraud Hotline 1-800-Medicare
Attorney General’s Office (billing and/or financial complaints) 402-471-2682