DHS Contractor/Vendor Name As Listed on DHS Contract or Agreement
(as shown on executed contract or agreement)
Incident Location (Provide Address Where Critical/Serious Incident Occured)
List name(s) of DHS employee(s) you frequently consult regarding this contract.
(e.g., Division of Family & Children Services, Division of Aging Services, Office of Inspector General, Office of Information Technology, etc., if known)
Incident Reporter's Information
Reporter's Name
Reason for Report
(Serious Incident means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual.)
(Critical Incidents are events outside the normal experience that pose actual or perceived threats of injury or exposure to death.)
Local Emergency Services Contacted
If Police Were Contacted