Facility Statistical Report Forms Information

KAR 28-39-163(d) Reports.  Each administrator shall submit to the licensing agency, not later than 10 days following the period covered a report of residents and employees.  The administrator shall submit the report on forms provided by the licensing agency.

Nursing facilities, assisted living facilities, residential health care facilities, home plus and nursing facilities for mental health are required to complete a facility statistical report.  The statistical report consists of two parts – Part I, Staffing and Part II, Residents.

This report is due on January 30th.  Refer any questions regarding completion of this report to Tina Lewis at (785) 296-1260 or by email at tina.lewis@kdads.ks.gov. For any technical questions contact the KDADS help desk at (785) 296-4987 by email at helpdesk@kdads.ks.gov.

To provide additional web application security each facility will need to complete the KDADS Security Agreement for any individual who will be accessing the facility statistical report web application.  The facility administrator or operator will need to authorize the Security Agreement for each individual who will need access.  KDADS will then issue the individual a personal user-name and an initial password.  The log-in information will be emailed to the address provided on the Security Agreement.

If any facility information is incorrect (facility name, address, licensure type, state ID, resident capacity, etc.) a change request will need to be submitted.   An on-line change request is available on the facility home page.

Where to find Statistical Report:

The statistical report is found on the facility home page located on the Kansas Organization Tracking Application (KOTA).  To access KOTA, go to www.kdads.ks.gov, click on KDADS Provider Information then click on Web Applications located on the right-hand side of the screen.

  1. Log on facility home page
  2. Scroll down to Facility Statistical Report
  3. Click on "Create New Report
  4. Select the facility type
  5. Select either Part I or Part II
  6. Enter information; and save.


Will open instructions for the forms, click on the Sample Form link to print a paper version of the form to enter to use to prepare prior to data entry.

On-line Reports:

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Page Last Updated: April 3, 2015