Investigation Target Notification
Client Name
First Name
Last Name
Allegation Primary Category
Abuse
Death
Exploitation
Neglect
Rights Violation
Serious Injury
Sexual Abuse
Suicide Atempt
Abuse Secondary Category
Psychological Abuse
Physical Abuse
Misapplication/Unauthorized restraint with injury
Misapplication/Unauthorized restraint without injury
Seclusion
Death Secondary Category
Natural Causes
Unexpected
Exploitation Secondary Category
Failure to obtain informed consent
Material Resources
Unpaid Labor
Medical Responsibilities or resources
Missing/Theft of Medications
Misuse/Theft of Funds
Room and Board
Neglect Secondary Category
Failure to provide medication management
Failure to provide needed care
Failure to provide needed supervision
Failure to provide protection from hazards
Moving Violation
Rights Violation Secondary Category
Civil/Legal
Communication
Health
Privacy
Services
Unauthorized Restrictive Procedure
Serious Injury Secondary Category
Injury Unexplained
Choking
Pressure Injury
Sexual Abuse Secondary Category
Rape
Sexual Harassment
Unwanted Sexual Contact
Other
Suicide Attempt Secondary Category
No Injury or illness that requires medical intervention
Injury or illness that requires medical intervention
Location of Incident (e.g. Group Home Name, Community Location, Job site)
Date of Incident if Known
-
Month
-
Day
Year
Date
Time of Incident (If Known)
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
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03
04
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56
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58
59
Minutes
AM
PM
AM/PM Option
Select number of targets (If applicable)
1
2
3
4
Target(s) suspended?
Yes
No
Suspension is required for:
Abuse - any subcategory
Sexual abuse - any subcategory
Target 1 (If Applicable)
First Name
Last Name
Date of Target 1 Suspension
-
Month
-
Day
Year
Date
Time of Target 1 Suspension
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
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28
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31
32
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39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Person Contacting Target 1
First Name
Last Name
Target 2 (If Applicable)
First Name
Last Name
Date of Target 2 Suspension
-
Month
-
Day
Year
Date
Time of Target 2 Suspension
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
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41
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44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Person Contacting Target 2
First Name
Last Name
Target 3 (If Applicable)
First Name
Last Name
Date of Target 3 Suspension
-
Month
-
Day
Year
Date
Time of Target 3 Suspension
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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18
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31
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35
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38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Person Contacting Target 3
First Name
Last Name
Target 4 (If Applicable)
First Name
Last Name
Date of Target 4 Suspension
-
Month
-
Day
Year
Date
Time of Target 4 Suspension
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Person Contacting Target 4
First Name
Last Name
Please Select Assistant Director
Des Cicci
Dana Krencik
Tracey Smith
Breanna Marshall
Karen Gleason
Danell Stover
Alexis Houser
Name of person completing this form
First Name
Last Name
EIM Incident Number
Title of person completing this form
Submit
Should be Empty: