Report Date: : Time: a.m. p.m. Incident Date: : Time: : a.m. p.m.

Reporter’s Name and Title:

Address (city, state, zip code):

Phone: (area code and number):

Subject’s Name:

Address (city, state, zip code):

Type of residence:	Agency:

DDS Number:	Date of Birth:	Sex: Male Female Class Member: Y N

TYPE: Abuse Neglect Psychological Abuse Verbal Abuse Financial Exploitation

Alleged Perpetrator:	Relationship to Subject:

Location of Incident:

Description of Incident:

Action Taken:

Investigation to be Conducted by:

Others Notified: OPA DCF DSS	Name:	Date:

DDS Abuse/Neglect Liaison	Name:	Date:

DPH	Name:	Date:

Local Police	State Police	Name:	Date:

Agency	Name:	Date:

DDS Case Manager	Name:	Date:

Parent Guardian Advocate	Name:	Date:

DDS Director of Investigations	Name:	Date:

DDS Lead Investigator	Name:	Date:

DDS Internal Audit Unit (Financial Exploitation)	Name:	Date:

Person Completing Form and Title:

_____________________________________________________________________	Date:

Entered into eCAMRIS by: Name:	Date: Region:

Department of Developmental Services

June 2009 Intake Form for Allegations of

Abuse/Neglect/Psychological Abuse/Verbal Abuse/Financial Exploitation

Department of Developmental Services

EganK

2009-08-24

State of Connecticut