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Effective Date: 6/2019
Form 6111 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility. Form 6111 is required for transfusion related fatalities.
Submit as soon as possible and submit each form separately. Do not submit multiple incidents in one document.
Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments so that HHSC may review the incident without requiring additional information or documents.
Submit each completed form by ONE of the following (email, fax or mail):
Fax: 1-833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030
Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.
Date of Report – Enter the report date.
Date of Death – Enter the date of death.
Time of Death – Enter the time of death and check A.M. or P.M.
Facility License No. – Enter the facility license number.
Facility Provider No. (CCN) – Enter the facility provider number, which is the Medicare six-digit number.
Facility Name – Enter the name of the facility.
Facility Address – Enter the street address, city, state, ZIP code.
Telephone – Enter the area code and telephone number.
Reporter Name and Title – Enter the contact person and title that the surveyor will ask for should a follow-up telephone call be needed.
Primary Phone No. and Secondary Phone No. – Enter the area code and telephone numbers.
Email – Enter the email address.
Patient Name – Enter the first, middle and last name.
Date of Birth – Enter the patient’s date of birth.
Date of Transfusion – Enter the date the transfusion date.
Diagnoses (all) – Enter the diagnoses.
Where was patient when reaction occurred? – Check the box for home, hospital, nursing home, infusion center or other. If other, provide where.
Facility Name and City – Enter the name of the facility and city.
When did you first learn of the incident? – Enter the date and time.
On what shift did the incident occur? – Check the box for day, evening or night.
Provide a brief summary – Enter what happened and include relevant staff names and titles, dates and time. Include information pertaining to whether or not the patient was transferred prior to death.
Did the patient receive any treatment? – Check Yes or No and if yes, provide an explanation of the treatment provided. Attach pertinent treatment documentation, if necessary.
Provide a narrative report of the investigation – Explain how the incident was handled and what actions were taken to reduce the potential for similar incidents in the future.
Actions to be taken as a result of this incident – Check all boxes that apply.
Signature, Printed Name and Date – The supervising authority signs, prints his/her name and enters the date. Then, email, fax or mail the completed incident form to the number or address provided above under Transmittal.