Incident Reporting Forms & Documents

If you need assistance:

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

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: Lynn Trotter
2. When reporting restrictive interventions, complete and submit BOTH forms
3. Please be sure that the report is legible