Long Term Care Incident Report - Illinois
13 hours ago Report Type Initial. Final Incident Date: Time of Incident Facility Type. SNF. ICF SC. CLFAddress Resident to Resident Altercation Severe Injury of Unknown Origin. Other Date of Birth License Number Name. Staff #1 Involved in Incident. Position Suspended Yes. No. Terminated Yes. NoBed Bound. Resident #2 Involved in Incident. Name Victim ... >> Go To The Portal
Who can use the incident report form?
This form may be used by acute care and long term care facilities, centers, agencies, or clinics to notify the IDOH of a reportable incident. The Incident Report Form is not to be used by covered individuals to report a reasonable suspicion of a crime against a long term care facility resident or by consumers to file a complaint.
How do I contact Illinois Department of Public Health (IDPH)?
Contact the IDPH Helpdesk at 866-220-5247 or via email at DPH.Helpdesk@illinois.gov for Portal access and web-based application support. Please include your name, phone number, and specific application name, detail of the issue and error messages, if any, in your description of the problem within the email message to ensure efficient resolution.
What can I do with IDPH?
Join online communities to share files, discussions, calendars and more. Access Web-based applications. Requirements: To access the IDPH Web Portal, users must be running Internet Explorer 9.0 or higher. Some portal applications may not function properly with other browsers such as Mozilla Firefox.
Can a long term care facility report an incident?
The Incident Report Form is not to be used by covered individuals to report a reasonable suspicion of a crime against a long term care facility resident or by consumers to file a complaint. The preferred method to report an incident is through the IDOH Incident Reporting System.
Forms
If the Online Incident Reporting System is nonoperational, the Incident Reporting Form must be completed and emailed to incidents@isdh.in.gov.
How to Report an Incident to the IDOH
The preferred method to report an incident is through the IDOH Incident Reporting System. The Incident Reporting System is an online system located on the IDOH Gateway at the same location as the Survey Report System. Health care facilities can access the Gateway at https://gateway.isdh.in.gov/.
Report Submission
All incident report information must be submitted through the Online Incident Reporting System effective July 1, 2015.
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