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: https://ucoa.utah.edu/coreissues/directives/index.php
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 [Assisted Living and ICF/IID only]
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.
Core Competency Documents
Entity Reports and Follow Up Investigations
Entity Reports and Follow Up Investigations.
Exhibit 358 - Sample Form for Facility Reported Incidents
Exhibit 359 - Follow-up Investigation Report
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
Personal Care Aide Evaluation
Facility/Agency Info for the Licensing Application Process