NMDOH

The Division of Health Improvement

IROnline

Health Facility Incident Report Form

All licensed health care facilities shall conduct a complete investigation and report the actions taken and conclusions reached by the facility within five (5) business days of the initial Incident Report.

Please answer all questions to the best of your ability, some fields are required. Address only one event per report.

Report Type:

Is this the initial report?
Is this a follow-up report?

Facility Information:

Facility Name *

Facility License Number
Facility Phone Number

Facility Address

Facility Reporter Name *
Facility Reporter Title

Facility Reporter Phone *
Facility Email Contact

Type of Incident:

Incident Description:

Resident Name *
Resident Date of Birth *

Diagnosis:

Resident Diagnosis *

Check all that apply

Incident Outcome and Notifications:

Perpetrator:

Responsible Party:

Interventions Implemented:

Email Copy of Report To

Facility Information:

Facility Name *

Facility License Number
Facility Phone Number

Facility Address

Administrator Name

Follow-Up Details:

Complaint narrative investigation follow-up report (5 day)

Resident Name *
Resident Date of Birth *

If allegations of abuse, neglect, or exploitation are substantiated or unsubstantiated
Initial Report Number If you know the initial report number for this incident, you can enter it here to link the two reports in the system

Report Completed by *

Email Copy of Report To