Client Name	Incident Date:

For purposes of the DDS Abuse/Neglect Registry, summary of DDS monitoring activities/procedures of a private agency/vendor investigation: {(A) confirming the accuracy of witness statements, (B) confirming the sources, documentation and evidence relied upon in the investigation, and (C) conducting such supervision and review activities as may be sufficient, in the exercise of professional judgment by an investigator employed by the authorized agency and trained by the State of Connecticut, to confirm that the finding(s) are supported by a preponderance of evidence)}

Abuse Substantiated	Neglect Substantiated

Summary of basis for substantiation:

DDS is in agreement with investigation findings.	Yes	No

DDS confirms, on the basis of this investigation, that abuse/neglect is substantiated by a preponderance of evidence.

________________________ ______________________________________________________________

Date	DDS Lead Investigator

Department of Developmental Services

DDS Abuse/Neglect Registry:Monitoring Form

DDS A/N Registry: Monitoring Form

February 2009

If applicable for purposes of the DMR Abuse/Neglect Registry, summary of DMR monitoring activities/procedures: {(A) confirming

EganK

2009-06-17

State of Connecticut