Forms and documents
The documents, forms, and checklists listed on this page are made available to assist providers with maintaining compliance. Some of the documents here are mandatory while others are offered as a reference.
Health facilities program forms
OLST – Order for Life-Sustaining Treatment
- Life with Dignity (OLST) – (English)
- Life with Dignity (OLST) – (Spanish)
- OLST Conversation Guid
For more information regarding OLST and Advance Directives, see the Utah Commission on Aging website.
Core competency tools for assisted living providers:
Facility Reported Incidents for Nursing Homes ONLY (Medicare and/or Medicaid certified):
- DLBC – HS Form 358: Facility Reported Incident Initial Report
- DLBC – HS Form 359: Follow-Up Investigation Report
Facility Reported Incidents for ALL Non-Nursing Home Providers (ALF, ICF/IID, HH, Hospice, ESRD, etc…)
- Please submit incident reports through your Office of Licensing Provider Portal at provider.dlbc.utah.gov
- For instructions on using your Office of Licensing Provider Portal and submitting critical incidents, please review our DLBC provider portal tour
- R432-100 | General Hospital
- R432-101 | Specialty Hospital
- R432-152 | ICF-IID
- R432-270 | Assisted Living Facility
- R432-300 | Small Health Care Facility Type N
- R432-550 | Birthing Centers
- R432-500 | Freestanding Ambulatory Surgical Center
- R432-600 | Abortion Clinic
- R432-700 | Home Health Agency
- R432-725 | Personal Care Agency
- R432-750 | Hospice
- R432-950 | Mammography
- Applicable Rules by Provider Type
- Assisted Living Assessment Form
- Assisted Living Hospice Evacuation Example Form
- Assisted Living Nursing Guidelines
- Assisted Living Service Plan
- Competency Training Record
- Incident Report
- Inservice Training Record
- Negotiated Risk Contract
- Orientation Training Record
- Personal Care Aide Evaluation