Form Dmhas - Initial Incident Report Form October 2015 Page 2
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3Initial 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.
Consumer(s) Involved
Complete all information below for each individual consumer involved in this incident (attach additional sheets if needed).
1) First Name: ________________________________________ Last Name: _________________________________________
2) Date of Birth: ____________________ 3) Gender: ____________________
4) Phone: ____________________
5) Address: _____________________________________________________________________________________________
6) The role of the aforementioned consumer:
Alleged Victim
Alleged Perpetrator
7) Was this consumer on agency site or in presence of staff at the time of this incident?
Yes
No
If Yes: Agency Name: ___________________________________________________________________________________
Agency Site/Address: _____________________________________________________________________________
Agency Program Element: _________________________________________________________________________
8) Consumer’s Residential Service Provider’s information:
Level of care:
A+,
A,
B, or
C
Agency Name: ________________________________________________________________________________________
Agency Site/Address: ___________________________________________________________________________________
Agency Program Element: _______________________________________________________________________________
9) Is this consumer also served by the New Jersey Division of Developmental Disabilities (DDD)?
Yes
No
If Yes: Case Manager Name: ____________________________________________________
Case Manager Contact Information: ________________________________________
10) Identify other services (within or outside your agency) that this consumer is involved in, including MH and/or SUD:
Agency
Site
Program Element
11) How long has this consumer been receiving services from your agency (include date of admission)?
___________________________________________________________________________________________________
12) How often is this consumer seen by your agency? __________________________________________________________
The consumer’s scheduled number of hours _________ and scheduled number of days per week ____________________
The consumer’s actual number of hours of attended _________ and actual number of days attended per week _________
13) When was this consumer last seen by your agency PRIOR to the incident?
____________________________________________________________
Advisory, Consultative, Deliberative, Confidential Communication
NJ Department of Human Services 10-2015
Initial Incident Report Form
DMHAS
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