DHS OPRMI Correspondence - Add Allegation/Complaint

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Allegations/Complaints

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Allegations/Complaints

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NOTE ABOUT PRINTING:
We recommend you take note of the Allegation/Complaint record identifier. Your submission must be completed by clicking either the Save button on the top right corner of the screen or at the end of the form before attempting to print this form.
Use your web browser's built-in functionality to print by selecting Print from the File menu. Some browsers may allow you to right-clickanywhere on the page and select a Print shortcut.

* You will only be able to view and print your allegation/complaint from the link.
You will not be able to log into QuickBase to edit or email it. If you wish to change or add to your allegation/email complaint, please email oprmi@dc.gov with the Allegation/Complaint in the subject line and include any additional information and attachments in the email

Unusual Incident Report-
An alleged, suspected or actual event or occurrence that involves a DHS customer, employee, contractor, provider or volunteer and negatively affects or compromises the integrity of DHS programs, or threatens health or safety, or the safekeeping of District property.
Complaints-
Complaints are proposed changes or expressions of dissatisfaction about the content, quality or delivery of a DHS program or service. These are reported by persons receiving services through DHS or a DHS contractor.
Fraud-
Public assistance benefit fraud occurs when a person obtains or attempts to obtain any grant or payment of public assistance to which they are not entitled, or a larger amount of public assistance to which they are not entitled, by means of a false statement, failure to disclose information, impersonation or by other fraudulent device.

Select Form Type Here =>

PERSON REPORTING

Agency/Employee/Resident/Volunteer Reporting Incident *

Employer/Agency/Organization (please enter "N/A" if not applicable) *

Check if Person reporting wishes to remain anonymous. Must provide contact number or email.

Person Reporting

Prefix

First Name

Middle Name

Last Name

Address

Quadrant

Ward

City

State

Zip Code

Person Reporting Alias/First Name

Phone Number

Email Address *

Complaint Type

REFERRAL TYPE OR COMPLAINT RELATED TO PROGRAM

Discrimination

ADA

Facility & Environment

PII/Privacy/HIPAA Violation

Homeless Services/Shelters

Privacy

Customer Service

Eligibility/Benefits

Family Services

ESA Service Center

Other complaint/suggestions

Other complaint/suggestion - Describe

Unusual Incident Type

Abuse or Neglect

Assault

Threat

Medical Care

Domestic Violence

Death- Under Physician Care

Death- Not under Physician Care

Fire

Damage to government property

Injury

System Outage

Environmental Issue

Theft

Facility Maintenance or Repair

Mental Health Evaluation

Misconduct (Contractor/Subcontractor)

Misconduct (DHS Employee)

Employee/Contractor Misconduct Type

Vehicle Accident

Illness

Refusal of Medical Care

Waiver Completed

Program Rule Violation/Misconduct (Client)

Violation/Client Misconduct Type

Missing Persons

Missing Person Found

Discrimination(UI)

Facility & Environment (U/I)

PII/Privacy/HIPAA Violation

Controlled Substance

Drug Overdose

Was 911 called?

No
Yes
None of the above

Did Shelter Staff administer Narcan?

No
Yes
None of the above

Reason Narcan not administered

Was the person case manager notified?

No
Yes
None of the above

Was the person referred to treatment?

No
Yes
None of the above

Fraud

CHOOSE FRAUD REFERRAL TYPE

Dual Benefits

Income or Assets

Trafficking

Household Composition

Residency

Alleged Modified fraud Start Date

Alleged Modified fraud End Date

PROGRAMS (SELECT ALL THAT APPLY)

Student Care Subsidy

Food Stamps/SNAP

Medicaid

Medical Assistance

TANF

Program Type

UI Program Type

Location of Incident

LOCATION OF INCIDENT

Please enter Location of Incident. If you do not see your provider/program listed in the menu, please select "Other" and enter the location.
To suggest adding a new provider/program location, you may email oprmi@dc.gov.

Location of Incident *

Name of Facility

incident/Address

Incident/Address City

Incident/Address State

Incident/Address Zip Code

Date of Incident *

Time of Incident (MM:HH AM/PM) *

PERSON(S) OF INTEREST

Person of Interest #1

1. First Name *

Last Name *

HMIS Number

Date of Birth

Phone Number

Address

Person of Interest #2

2. First Name

Last Name

HMIS Number PI-2

Person of Interest2 DOB

Phone Number

Address

Person of Interest #3

3. First Name

Last Name

HMIS Number PI-3

Person of Interest3 DOB

Phone Number

Address

WITNESSES

Witness #1

1. First Name

Last Name

Phone Number

Address

Witness #2

2. First Name

Last Name

Phone Number

Address

Witness #3

3. First Name

Last Name

Phone Number

Address

DESCRIPTION

Description of Allegations, Unusual Incident or Complaint *

UIR Report Attachment

Admin (Temp)

Fiscal Year

Date on Allegation/Complaint *

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When you bring additional fields into a conversion, Quickbase often finds inconsistencies. For example, say you're converting your Companies column into its own table. One company, Acme Corporation, has offices in New York, Dallas and Portland. So, when you add the City column to the conversion, Quickbase finds three different locations for Acme. A single value in the column you're converting can only match one value in any additional field. Quickbase needs you to clean up the extra cities before it can create your new table. To do so, you have one of two choices:

If you want to create three separate Acme records (Acme-New York, Acme-Dallas and Acme-Portland) click the Conform link at the top of the column.
If the dissimilar entries are mistakes (say Acme only has one office in New York and the other locations are data-entry errors) go back into your table and correct the inconsistencies�in this case, changing all locations to New York. Then try the conversion again.

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