Investigation Target Notification

Investigation Target Notification
Client Name

First NameLast Name
Allegation Primary Category
Abuse Secondary Category
Death Secondary Category
Exploitation Secondary Category
Neglect Secondary Category
Rights Violation Secondary Category
Serious Injury Secondary Category
Sexual Abuse Secondary Category
Suicide Attempt Secondary Category
Location of Incident (e.g. Group Home Name, Community Location, Job site)
Date of Incident if Known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Incident (If Known)

:HourMinutesAM/PM Option
Select number of targets (If applicable)
Target(s) temporarily removed from duty?
Removal from duty is required for:
Target 1 (If Applicable)

First NameLast Name
Date of Target 1 temporarily removed from duty.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Target 1 temporarily removed from duty.

:HourMinutesAM/PM Option
Person Contacting Target 1

First NameLast Name
Target 2 (If Applicable)

First NameLast Name
Date of Target 2 temporarily removed from duty.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Target 2 temporarily removed from duty.

:HourMinutesAM/PM Option
Person Contacting Target 2

First NameLast Name
Target 3 (If Applicable)

First NameLast Name
Date of Target 3 temporarily removed from duty.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Target 3 temporarily removed from duty.

:HourMinutesAM/PM Option
Person Contacting Target 3

First NameLast Name
Target 4 (If Applicable)

First NameLast Name
Date of Target 4 temporarily removed from duty.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Target 4 temporarily removed from duty.

:HourMinutesAM/PM Option
Person Contacting Target 4

First NameLast Name
Please Select Assistant Director
Name of person completing this form

First NameLast Name
EIM Incident Number
Title of person completing this form
Should be Empty: