Form Dmhas - Initial Incident Report Form October 2015 printable pdf download

Initial Incident Report Form

New Jersey Department of Human Services

Division of Mental Health & Addiction Services

Reports must be submitted no later than one (1) working day following the date the incident was known to the agency.

Submit reports to: dmhs.incidentrept@dhs.state.nj.us or Fax # 609-341-2324.

1) Date of Report: _______________________ 2) County: _______________________

3) Incident Date and Time: _________________________ 4) Date and Time known to Agency: _________________________

5) Alleged Victim Name(s): _______________________________________________________

_______________________________________________________

6) Alleged Perpetrator Name(s) (if applicable) and relationship to victim: ___________________________________________

___________________________________________

7) Identified witnesses (if applicable): _______________________________________________________

_______________________________________________________

8) Location of Incident: ___________________________________________________________________________________

9) Reporting Agency Name, Address & Program Element: ________________________________________________________

_______________________________________________________________________________________________________

10) Type of Incident: (check all appropriate categories)

Death, Expected

Alleged Exploitation

Death, Sudden and Unexpected

Alleged Neglect

Alleged Suicide Attempt

Alleged Verbal/Psychological Abuse

Alleged Physical Abuse

Criminal Activity

Alleged Physical Assault (Moderate/Major Injury)

Elopement/Walkaway

Alleged Sexual Abuse

Injury (Moderate/Major)

Alleged Sexual Assault

Overdose

Medical

Media Interest

Sexual Contact

Operational

Rights Violation

Contraband

11) Provide a detailed description of incident being reported:

___________________________________________________________________________________________________

DMHAS USE ONLY

UIRMS #: _________________ Primary Code: ___________ Secondary Code: ___________ Closing Entity: ________________

Advisory, Consultative, Deliberative, Confidential Communication

NJ Department of Human Services 10-2015

Initial Incident Report Form

DMHAS

Form Dmhas - Initial Incident Report Form October 2015

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