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Documents
Instructions
Effective Date: 4/2025
Purpose
A facility uses Form 6101 to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.
Procedure
Submit each form within the required time frame:
- Report within 48 hours:
- If a mother or a newborn remains at the birthing center for medical reasons for more than 24 hours after birth, the birthing center must file a report after the birth to describe the circumstances and reasons for the extended stay.
- Within five calendar days of their occurrence:
- Death of a patient, newborn or death of a fetus during the course of labor that occurred in the center.
- Death of a patient or newborn that occurred within 24 hours of discharge from the center or transfer to another health care facility.
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 HHSC may review the incident without requiring additional information or documents.
Transmittal
Submit each completed form by one of the following:
Email: CII.HCQ@hhs.texas.gov
Fax: 833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E249
Austin, TX 78714-9030
Detailed Instructions
Section 1 – Reportable Incident
Print or type the information and provide as much information as possible. Note: Use the facility name and license number as listed on your license.
Reportable Incident – Mark the appropriate box:
- If a mother or a newborn remains at the birthing center for medical reasons for more than 24 hours after birth, the birthing center must file a report after the birth and describe the circumstances and reasons for the extended stay.
- Death of a patient, newborn or death of a fetus during the course of labor that occurred in the center.
- Death of a patient or newborn that occurred within 24 hours of discharge from the center or transfer to another health care facility.
Date of Report – Enter the report date.
Date of Incident – Enter the date of the incident.
Time of Incident – Enter the time of the incident and check A.M. or P.M.
Facility License No. – Enter the facility license number.
Facility Name – Enter the name of the facility.
Facility Street Address, City, State and ZIP Code – As stated.
Facility Area Code and Phone No. – Enter the area code and phone number.
Reporter Name – Enter the person the surveyor will ask for should a follow-up phone call be needed.
Title – Enter the title the surveyor will ask for should a follow-up phone call be needed.
Primary Area Code and Phone No. – Enter the area code and phone numbers.
Secondary Area Code and Phone No. – Enter the area code and phone numbers.
Email – Enter the email address.
Section 2 – Patient and Baby Information
Patient Information:
Patient Name – If the incident involves a patient, enter the first, middle and last name.
Date of Birth – Enter the patient’s date of birth.
Gestation – Enter the weeks and days for gestation.
Gravida and Parity – Enter the gravida and parity.
Date Admitted to Current Facility – Enter the date the patient was admitted.
Date of Discharge – Enter the date of discharge.
Date and Time of Death – Enter the date and time the patient died.
Cause of Death – Enter the suspected cause of death.
Diagnoses, including prenatal and related or pre-existing – Enter the diagnoses.
Baby Information 1 and 2:
Note: If incident involves more than two fetuses or infants, attach additional documentation.
Date and Time of Death – Enter date and time of death.
Cause of Death – Enter the suspected cause of death.
Baby Name – Enter the baby’s first, middle and last name.
Baby Date of Birth or Event – Enter the date of birth or date of event.
Baby Sex – Check male or female.
Time of Death – Enter the hour and minute of death.
Date of Discharge – Enter the date of discharge.
Diagnoses – Enter the diagnoses.
Date and Time of Death – Enter the date and time the patient died.
Section 3 – Physician Information
Name and Title of treating physician, certified-nurse midwife or licensed midwife – Enter the first and last name and title of the physician, certified-nurse midwife or licensed midwife and their license number.
Section 4 – Witness Information
Witness Name – Enter the first, middle and last name of the witness. Witnesses can include other patients, staff members, family members or friends.
Title – Enter the title of the witness if the witness is a staff member.
Area Code and Phone No. – Enter the area code and phone number of the witness.
Section 5 – Alleged Perpetrator Information
Alleged Perpetrator Name – Enter the alleged perpetrator’s name. List only alleged perpetrators who are not patients. Alleged perpetrators who are patients should be listed in the Patient section. If the alleged perpetrator is not a patient or a staff member, indicate the relationship of this person to the patient, such as friend or family member.
Title – Enter the alleged perpetrator’s title. If the alleged perpetrator is not a patient or a staff member, indicate the relationship of this person to the patient, such as friend or family member.
License No. – Enter the alleged perpetrator’s license number.
Social Security No. – Enter the alleged perpetrator’s Social Security number.
Area Code and Phone No. – Enter the alleged perpetrator’s area code and phone number.
Alleged Perpetrator Street Address, City, State and ZIP Code – Enter the alleged perpetrator’s street address, city, state and ZIP Code.
Section 6 – Summary
When did you first learn of the incident? – Enter the date and time.
On what shift did the incident occur? – Mark day, evening or night.
At what state of the labor or delivery was the issue identified, such as beginning of labor or middle of delivery? – Enter when the issue was identified within the state of labor or delivery.
Provide a brief summary – Enter what happened, who was involved, such as an RN, LVN, patient care technician (PCT), MD or other, and the action taken at the time of the incident.
Did the patient receive any treatment at the birthing center? – Check Yes or No. If yes explain the treatment provided to the mother, fetus or both, or treatment provided to the mother, infant or both. Attach pertinent treatment documentation if necessary.
Did the mother or a newborn remain at the birthing center for medical reasons for more than 24 hours after birth? – Check Yes or No. If yes describe the circumstances and reasons for the extended stay at the birthing center.