GRAMA (Information) Request Form

Request for Administrative Review

Electronic Complaint Form

These tools are available for use and are not required. 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

Core Competency Documents

Approved Trainings

Required Coversheet

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…)

DLBC- Facility Reported Incident Form

Orientation Training Record

Competency Training Record

Inservice Training Record

Assisted Living Service Plan

Assisted Living Hospice Evacuation Example Form

Assisted Living Requested Information for Survey

Negotiated Risk Contract

Variance Request Application

Incident Report

Personal Care Aide Evaluation

Information Sheet – Facility/Agency Licensing

Fee Schedule – Fiscal Year 2023 (July 1, 2022 – June 30, 2023)

Fee Schedule – Fiscal Year 2022 (July 1, 2021 – June 30, 2022)

Notice of Intent

License Application

Certificate of Fire Clearance

Satellite Notice of Intent

Mammography Application

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

Applicable Rules By Facility Type

Assisted Living Facility Type I & II- Resident Assessment (New Version)

PRN and STAT Medication Administration Record

Medication Record

Employee Health Evaluation