Health Facility Forms

POLST - Life with Dignity Order

POLST - Life with Dignity Order (Provider Order for Life Sustaining Treatment)

Life with Dignity (POLST) - (english)

Life with Dignity (POLST) - (spanish)

POLST Conversation Guide

For more information regarding POLST and Advance Directives, see the Utah Commission on Aging Website at:

GRAMA (Information) Request Form

Request for Administrative Review

Electronic Health Care Facility Complaint Submission

Instructions For Forms

• Please print out desired form. If you wish, you may fill out online, but you MUST print the form when done.

• Please mail or fax to the address in the upper right corner of the form. For safety and privacy concerns we do not store the form data in any online database. You cannot submit any forms via this web page.

Electronic Complaint Form
Electronic Entity Report Form

Guidance Tools for Nursing Homes

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 and Training Checklist

Core competency tools for assisted living providers.

Training Checklist
Core Competency Documents
Approved Trainings

Other Helpful Provider Forms

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
Patient Safety Sentinel Event Reporting Form
Negotiated Risk Contract
Variance Request Application
Incident Report

Personal Care Aide Evaluation

Facility/Agency Info for the Licensing Application Process


Fee Schedule
License Application
6. Satellite Notice of Intent
7. Mammography Application
















Criminal Background Screening