Dhr incident intake report form 2026

1. Click ‘Get Form’ to open the dhr incident intake report form in the editor.
2. Begin by filling out the 'Incident Intake Information' section. Enter the Facility ID, Date, Satellite Location, Facility Name, License Number, Site Address, and contact details including Telephone and E-mail.
3. In the 'Reporter' section, provide your first name, last name, middle initial, email address, phone number, and position/title.
4. Check all applicable boxes under 'Reason for Report' to indicate the nature of the incident. This includes options like Physical Abuse and Serious Injury.
5. Complete the 'CPS Notification' section if required. Fill in the name of the notifying party and their county and office number.
6. For each child involved in the incident, fill out their personal information in the 'Child/Resident' section including first name, last name, date of birth, gender, and placement details.
7. Provide detailed descriptions in sections regarding how injuries occurred and any medical attention given. Ensure to include a summary of the incident at the end.

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