Incident Reporting Forms & Documents

If you need assistance:

Please see the Provider and Consumer Relations Department for a list of personnel you can contact.

Incident Response Improvement System (IRIS)

The Department of Health and Human Services (DHHS) Incident Response Improvement System (IRIS) is a web based incident reporting system for reporting and documenting responses to Level II and III incidents involving consumers receiving mental health, developmental disabilities, and/or substance abuse services (mh/dd/sas).  Providers of publicly funded services licensed under NC General Statutes 122C (Category A providers), except hospitals, and providers of publicly funded non-licensed periodic or community-based mh/dd/sa services (Category B providers) are required to report these incidents.  This technical manual provides instructions for these providers to enter information regarding these incidents into the IRIS system.  Click here to access the IRIS Technical Manual.

Level I Incidents

Please fill out the Level I Quarterly Report Form.

Level II and III Incidents

We are only accepting the DHHS Incident & Death Reporting Form marked Form QMO2 "Effective October, 2004 - Rev. 3/8/06" and DHHS Restrictive Intervention Details Report Form QMO4 "Effective October, 2004 - Rev. 11/18/04".

Link to the Critical Incident and Death Report Form QM02 on the NC DHHS website

Link to the Restrictive Intervention Details Report QM04 on the NC DHHS website

Link to the Incident Reporting Manual on the NC DHHS website

** If you encounter any difficulties obtaining these forms by using the links we have provided, try going directly to the website for DHHS, Division of MH/DD/SAS. As of 10/09/06 the above forms were located on the site at:

http://www.dhhs.state.nc.us/mhddsas/

Follow the links for "Statistics and Publications" then "Manuals and Forms"

Other Reminders:

1. The fax number is (828) 225-2784, att: Kris Booker
2. When reporting restrictive interventions, complete and submit BOTH forms
3. Please be sure that the report is legible

---

Add this page to your favorite Social Bookmarking websites