Major Injury Determination Form – Fill Out and Use This PDF

Updated: Nov 14, 2026

The Major Injury Determination Form is an essential document used in situations where a facility must determine if an injury sustained by a person is major, relying on the expertise of a physician, designee, or extender. This form ensures that the injury is properly assessed within a specific timeframe, and it sets out the steps to be followed after the determination. For those looking to ensure timely and accurate reporting of major injuries, accessing and completing this form is crucial.

For detailed guidance on how to properly fill out this form and submit it as required, click the button below.

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How to Fill Out Major Injury Determination Form

Major Injury Determination Form at a glance

What it is: The Major Injury Determination Form must be completed if the facility is relying on the physician, designee, or extender to determine whether a major injury has occurred.

Who signs: The facility representative completing the Form signs on the Signature of Facility Representative Completing Form line and fills in Print Name, Date and Time. The physician, designee of the physician, or physician extender signs on the Signature of Physician, Designee of Physician, or Physician Extender line and fills in Date and Time. They state that they have made the determination of whether the patient's injury should be designated as a major injury pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3) or is NOT a major injury, based on the disclosure of the information available on this date.

The blank Major Injury Determination Form: print it and complete it by hand

Major Injury Determination Form blank form, page 1 — This form has no fillable fields. Print it and complete it by hand, or use the editor to type on it.

How to fill out Major Injury Determination Form, box by box

To be completed by the facility

Write the Resident name.

Write the Date and time of the injury.

Write the Description of injury.

Write the Circumstances of the incident causing the injury.

Write the Resident's previous functional ability.

Within 24 hours, 72 hours or one business day

The facility shall submit this Form to the Physician, Designee, or Extender within 24 hours of when the injury occurred.

The facility must obtain a signed copy of this Form from the physician, designee, or extender within 72 hours of the injury.

If the physician, designee, or extender refuses to complete the Form or is unavailable for completion and signature, the DIA Director (or designee) must be notified of the injury within one business day.

To be completed by the physician, designee, or extender

The physician, designee, or extender writes the Patient's prognosis.

Check one: the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3), or the injury sustained is NOT a major injury and, to the best of my knowledge, barring any complications, the patient will return to his/her previous functional status. The physician, designee, or extender prints their name on the line after I. They state that they have read this Determination Form and know the content thereof. They also state that they have made the determination of whether the patient's injury should be designated as a major injury based on the disclosure of the information available on this date.

Designee means another physician or physician extender in lieu of the attending physician.

If the physician, designee or extender determines

If the physician, designee or extender determines a major injury has occurred, the facility maintains the signed Form in the resident's clinical record and notifies the department of the major injury.

If the physician, designee, or extender determines the injury sustained is not a major injury, the facility maintains the signed Form with the resident's clinical record.

More rules for Major Injury Determination Form

The facility may independently determine that a major injury has occurred and submit a self report.

Sources

[1] Major Injury Determination Form (Iowa DIA, 481 Iowa Administrative Code 50.7) (the Official source link on this page).

Major Injury Determination Form PDF Details

In the complex landscape of healthcare and patient care management, the Major Injury Determination Form serves as a critical tool for formalizing the evaluation process of injuries sustained by individuals in care facilities. This document, integral to the decision-making pathway, mandates collaboration between the facility and medical professionals to ascertain the severity of an injury and to ensure appropriate follow-up actions are taken. Essential highlights of the form include the necessity for its completion when a facility elects to rely on a physician, their designee, or an extender to determine the occurrence of a major injury rather than making an autonomous assessment. It outlines a clear timeframe within which the form must be submitted to and signed by the healthcare professional—specifically, within 24 hours for submission and 72 hours for obtaining a signed copy post-injury. The procedure for situations where a medical professional cannot or will not complete the form is also covered, emphasizing the need for prompt notification of the DIA Director (or designee) about the injury. Furthermore, the outcome of this determination—whether a major injury did occur—triggers distinct documentation and reporting requirements, each designed to protect the patient and to ensure regulatory compliance. Details required from the facility include the resident's name, injury specifics, and previous functional ability, fostering a comprehensive view of the incident. The medical professional's portion seeks a prognosis, making the distinction between major and non-major injuries, thus guiding the future care path for the resident. This form is not merely bureaucratic; it embodies a systematic approach to handle injuries in care environments diligently, ensuring the welfare of the resident is prioritized and the operational integrity of the facility is maintained.

Question	Answer
Form Name	Major Injury Determination Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	nonmajorinjury form iowa, dia major injury determination form, iowa major injury determination form, injury determination form