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CMS Facility-Reported Incident: Initial Reporting Form

Wednesday, October 11, 2023 - 12:00

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CMS-Facility-Reported-Incident-Initial-Reporting-Form.pdf (189.76 KB)

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Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury, VT 05671-2060
(802) 241-0344

For Telecommunications Relay Service: Dial 711

Adult Protective Services Reporting Line
(800) 564-1612

Healthcare Organization Complaint Reporting Line
(888) 700-5330

Joe Nusbaum
Division Director

John Gordon
Adult Protective Services Director

Suzanne Leavitt
Survey and Certification Director

This is a Division of the
Department of Disabilities, Aging and Independent Living
under the Agency of Human Services

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