* = Required Information

Complete the DAY OF or the 1st BUSINESS DAY AFTER calling the CEP/CP of a maltreatment incident

Abuse Neglet Financial Exploitation
Yes No

Incident

TIME OF INCIDENT:


INTERNAL REPORTER LEARNED OF INCIDENT:


INTERNAL REPORTER INFORMED MANDATED REPORTER:


MANDATED REPORTER CALLED CEP/CP:


CEP/CP Actions

Yes No
Yes No
Yes No

CEP/CP Information

Individual/IDT Information

Male Female

Reporter Information

MANDATED REPORTER

INTERNAL REPORTER

Alleged Perpetrator(s) Information

Description (Optional)

Male Female
Yes No

If yes, complete program information below:

DHS Health
Yes No

Witnesses

Documentation & Notification

Initial Disposition Final Disposition
Program Specialist Internal Maltreatment Investigator

Attach the INCIDENT/ACCIDENT REPORT and NOTIFICATION TO AN INTERNAL REPORTER to this form.

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