DHS OIG Critical and Serious Incidents Form

DHS Contractor/Vendor Name As Listed on DHS Contract or Agreement

(as shown on executed contract or agreement)

DHS Contract or Agreement Number (required)

Incident Location (Provide Address Where Critical/Serious Incident Occurred)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contractor/Vendor Phone Number

Contractor/Vendor Email Address

DHS Point of Contact (required)

List name(s) of DHS employee(s) you frequently consult regarding this contract.

DHS Business Unit

(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

First

Last

Reporter's Phone Number

Reporter's Email Address

Reason for Report

Physical Abuse Allegation

Serious Incident

(Serious Incident means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual.)

Neglect, Sexual Abuse, or Exploitation Allegation

Death of Resident in Contractor’s Care

Critical Incident

(Critical Incidents are events outside the normal experience that pose actual or perceived threats of injury or exposure to death.)

Local Emergency Services Contacted

Police

Fire

Medical

None of the above

If Police Were Contacted

Law Enforcement Jurisdiction

Report Number

Details of Incident

DHS OIG Critical and Serious Incidents Form

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Message

Mail