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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
Level I Incident Quarterly Review Report Form QM11 Word File
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
** 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:
- The fax number is (828) 225-2784, att: Lynn Trotter
- When reporting restrictive interventions, complete and submit BOTH forms
- Please be sure that the report is legible