Health Facility Forms

• GRAMA (Information) Request Form opens in a new tab
• Request for Administrative Review opens in a new tab

• Electronic Complaint Form opens in a new tab

These tools are available for use and are not required. The use of the tools does not assure regulatory compliance.

• Resident-to-Resident Altercation Flowchart
• Injury of Unknown Source Flowchart

Core competency tools for assisted living providers:

• Training Checklist opens in a new tab
• Core Competency Documents opens in a new tab
• Approved Trainings opens in a new tab
• Required Coversheet opens in a new tab

Facility Reported Incidents for Nursing Homes ONLY (Medicare and/or Medicaid certified):

• DLBC – HS Form 358: Facility Reported Incident Initial Report opens in a new tab
• DLBC – HS Form 359: Follow-Up Investigation Report opens in a new tab

Facility Reported Incidents for ALL Non-Nursing Home Providers (ALF, ICF/IID, HH, Hospice, ESRD, etc…)

• DLBC- Facility Reported Incident Form opens in a new tab

• Orientation Training Record opens in a new tab
• Competency Training Record opens in a new tab
• Inservice Training Record opens in a new tab
• Assisted Living Service Plan opens in a new tab
• Assisted Living Hospice Evacuation Example Form opens in a new tab
• Assisted Living Requested Information for Survey opens in a new tab
• Negotiated Risk Contract opens in a new tab
• Variance Request Application opens in a new tab
• Incident Report opens in a new tab
• Personal Care Aide Evaluation opens in a new tab

• Information Sheet – Facility/Agency Licensing opens in a new tab
• Fee Schedule – Fiscal Year 2024 (July 1, 2023 – June 30, 2024) opens in a new tab
• Fee Schedule – Fiscal Year 2023 (July 1, 2022 – June 30, 2023) opens in a new tab
• Fee Schedule – Fiscal Year 2022 (July 1, 2021 – June 30, 2022) opens in a new tab
• Notice of Intent opens in a new tab
• License Application opens in a new tab
• Certificate of Fire Clearance opens in a new tab
• Satellite Notice of Intent opens in a new tab
• Mammography Application opens in a new tab
• Rural Healtchare Clinic Initial Requirements opens in a new tab

New Provider Orientation Schedule — by appointment due to Covid restrictions. Reach out via email to: mofa@utah.gov opens in a new tab

• Applicable Rules By Facility Type opens in a new tab
• Assisted Living Facility Type I & II- Resident Assessment (New Version) opens in a new tab
• PRN and STAT Medication Administration Record opens in a new tab
• Medication Record opens in a new tab
• Employee Health Evaluation opens in a new tab

• Request for Administrative Review – Background Screening opens in a new tab