DHS Policies #115: MVR and #504: Self Reporting

Pursuant to Executive Order 04.01.21.57 and Department of Human Services (DHS) Policy 1201, all DHS employees are expected to maintain and exercise at all times the highest moral and ethical standards in carrying out their responsibilities and functions. On and off duty, DHS employees are expected to adhere to the provisions of DHS Policies #115 and #504. This form should be used to report non-compliance of DHS Policies #115 and #504. Staff are encouraged to review DHS Policies #115 and #504 in ODIS prior to completing and submitting this form

Employee name (please list your name as it appears in PeopleSoft)

First (required)

Middle initial (required)

Last (required)

Employee ID (required)

Employee email address (required)

Employee office/division (required)

Region # (if applicable)

Employee job title (required)

Driver's license number (required)

State of Driver's License (required)

Date of policy violation (required)

Please follow this link to ODIS for additional guidance regarding each policy violation.

Circumstances of policy violation (required)

Supervisor name

First (required)

Last (required)

Supervisor contact information

Phone

DHS Policies #115: MVR and #504: Self Reporting

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