Supplemental Report by a Licensed Facility/Organization and NPDB

Entities reporting Licensed Health Professionals for adverse action, judgment, or settlement, as a result of a suit, claim or violation, to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For the Professional I am Reporting

Prefix

First Name

Last Name

Middle Initial

Suffix

Primary Phone

Alt Phone

Fax

Date of Birth

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Where did the incident occur?

Facility

Address

Patient or Client

Name

Date of Birth

Address

List all persons present at time of incident that would have first-hand knowledge of the incident.

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reporting Party Information

Business Name

Contact/Owner Prefix

Contact/Owner First Name

Contact/Owner Last Name

Contact/Owner Middle Initial

Contact/Owner Suffix

Primary Phone

Alt Phone

Fax

Email Address

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Is Mailing Address the same as Physical Address?

Yes

Mailing Address

Address Line 1

Address Line 2

PO Box

City

State

Zip Code

Relationship to Health Care Professional

Preferred method of contact:

Do you wish to remain anonymous?

Yes

ATTACH COPY OF NPDB (National Practitioner Data Bank) REPORT Attach any additional documentation.

Allowed file extensions: .tiff, .tif, .pdf, .doc, .docx, .jpg, .jpeg, .png and .gif
Max file size allowed: 20 MB.

The statements I have made are true and correct to the best of my knowledge. By signing this form, I am agreeing to the submission of this complaint by electronic means. I understand that an electronic signature has the same legal effect and enforceability as a written signature on a complaint.

Please sign by typing your name below.

Date

11/21/2024

Public Health Investigations

Department of Health and Human Services

Division of Public Health
Investigations - Healthcare Professionals and Occupations

Supplemental Report by a Licensed Facility/Organization and NPDB

Entities reporting Licensed Health Professionals for adverse action, judgment, or settlement, as a result of a suit, claim or violation, to the Division of Public Health – Investigations Unit.

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For the Professional I am Reporting

Physical Address

Mailing Address

Where did the incident occur?

Patient or Client

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reporting Party Information

Physical Address

Mailing Address

Supplemental Report by a Licensed Facility/Organization and NPDB

Entities reporting Licensed Health Professionals for adverse action, judgment, or settlement, as a result of a suit, claim or violation, to the Division of Public Health – Investigations Unit.

State of Nebraska Department of Health and Human Services, Division of Public Health Office of Professional & Occupational Investigations P.O. Box 94722, Lincoln, Nebraska 68509 PHONE: 402-471-0175 FAX: 402-742-8335 EMAIL: DHHS.InvestigationsPOL@nebraska.gov

Identifying Information For the Professional I am Reporting

Physical Address

Mailing Address

Where did the incident occur?

Patient or Client

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Reporting Party Information

Physical Address

Mailing Address

State of Nebraska
Department of Health and Human Services, Division of Public Health
Office of Professional & Occupational Investigations
P.O. Box 94722, Lincoln, Nebraska 68509
PHONE: 402-471-0175
FAX: 402-742-8335
EMAIL: DHHS.InvestigationsPOL@nebraska.gov