TX HHS Form 6109. Special Care Facility Incident Report

The TX HHS Form 6109, Special Care Facility Incident Report, is a critical document used to report incidents that occur in special care facilities. This form helps facility administrators and staff members document and report incidents such as abuse or neglect of children, elderly, or disabled individuals, fires causing injury or death, and other reportable events.

The form requires completion of specific information, including patient details (if applicable), incident description, and witness statements. Key sections include Patient Information, which captures essential data about the individual involved in the incident, and Witness Information, which collects details from staff members who witnessed the event. The form also includes important conditions, such as reporting abuse or neglect within 10 calendar days of occurrence.

This report should be used by special care facilities to document incidents that meet specific criteria outlined on the form. By completing this report, facility administrators can ensure compliance with regulations and take prompt action to address any issues that may have arisen. The TX HHS Form 6109 is a vital tool for maintaining a safe and responsible environment in special care facilities.