Adult Care Facility Incident Report DOH-5175 (DSS-3123)

Click here for guidance on DAL 23-02

Facility Information
Region
Level of Care
Check all that apply
Resident Information
Was a resident involved in this incident? (Please select no if reporting a facility event/interruption to essential services)
Resident Name (if necessary)
Type of Incident
Check all that apply
Resident Death Information (if applicable)
Did the resident receive aftercare OMH services?
Where did the person die?
Incident Detail
Resident Comments
If 'Yes', please go to the link below and attach a file of the resident comments. If resident declines or is unavailable for comment by time of submission, please collect form accordingly and maintain on file.
Resident Comments (If Yes)

Please Right Click Here and Open Link In New Tab to go to the Resident Comments Form. Complete the form and attach it below.

(Only required if resident prepared comments)
Upload requirements
Incident Reporting
Incident Reporting (Additional)
Reported to Name Date Reported
If Other, enter their title and name along with date.
Facility Administrator Name
Individual Reporting Incident
Individual's Name
Sign above