Incident Report Form
Incident Report Form - Submit the completed form by faxing or mailing (fax number and mailing address provided on form). To protect patient/resident confidentiality, please do not e-mail the Incident Report form. When an incident report is received, Healthcare Licensing and Surveys will investigate the occurrence and determine if appropriate facility action has been taken. Health surveyors also review incident reports prior to conducting annual surveys in facilities, and prior to reissuing a facility’s license. Incident reports may also be reviewed as part of a complaint investigation.
For reporting allegations of abuse, neglect, or misappropriation of resident property by Certified Nurse Aides in nursing care facilities and swing beds. Completed in addition to the above Incident Report Form.
Incident Report by healthcare facility - Fire/Explosion/Life Safety Code-Incident/Accident Report
Reportable Diseases and Conditions - Healthcare facilities are required to report Reportable Diseases and Conditions to the Wyoming Department of Health, Epidemiology Section. Those conditions classified as nosocomial (where two or more persons, either residents or employees, are affected) shall be reported immediately to the State Health Officer, the County Health Officer, and to Healthcare Licensing and Surveys.
Nursing home reporting requirements: Federal Requirements for Alleged Violations of Mistreatment, Neglect, and Abuse, including Injuries of Unknown Source and Misappropriation of Resident Property: CMS S&C-05-09