Neglect-COVID Intake form

Please complete this form with as much information and in as detailed a manner as possible. Upon receipt, your complaint will be reviewed by a member of our staff. A representative from the Pennsylvania Office of Attorney General, Care-Dependent Neglect Team, Medicaid Fraud Control Section, may contact you if additional information is needed.

Complainant Information (Reporting Person)

Your Name

First Last

Email

Daytime Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County

Your Profession/Occupation

General Nature of the Complaint (Check all that apply):

(There is space for a detailed narrative at the end of the form)

Have you already contacted any other government agency?

Yes
No

Who did you contact?

Law enforcement agency
Dept of Health
Dept of Aging
Dept of Human Services
Other

What law enforcement agency did you contact? *

Who did you contact? *

Name of the facility you are reporting

Address of the facility

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County facility is located within

Are you an employee of the facility?

No
Yes - Current Employee
Yes - Former Employee

Identify the type of facility, if known

Nursing Facility
Developmental Disability Facility Assisted
Living Facility
Hospital
Hospice
Personal Care Home
In-Patient Mental Health Facility
Other

What type of facility? *

Name of Affected Patient/Resident

First Last

Patient’s/Resident’s date of birth (if known)

Patient’s/Resident’s address (if known)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient’s/Resident’s contact information (if known)

Patient/Resident’s Responsible Party (POA, Guardian, etc.)

Responsible Party Contact Information (address, email, phone #)

Your relationship to the patient/resident

Date of incident(s):

Time of incident (if known):

Nature of Injury/Danger to Patient(s)/Resident(s):

Medical treatment, if any, required (include the name of any hospital where treatment was rendered)

Name and job title of persons who allegedly abused, neglected or mistreated the patient/resident

First Name	Last Name	Job Title

Name and job title of persons who witnessed the incident(s)

First Last Job Title

Witness Contact Info (phone/email)

Describe the incident in as much detail as possible below (include dates/times and names of people present):

Supporting Documents

If you would like to attach any additional photos or documents to support this form, upload those document below. Acceptable file types are images and PDFs. Max file size is 4MB and max total upload size is 10MB.

Drop files here or

Max. file size: 50 MB.