CIUSSS West-Central Montreal | Initial maltreatment report form

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Initial reporting of maltreatment

1. Person submitting the report:

First name (Person submitting the report)*

Last name*

Phone number*

Email*

Relation to the allegedly maltreated person*

Family member

Close circle

Health and/or social service provider

If you are a Health and/or social service provider, please specify - Title / Program / Directorate

2. Vulnerable person / Person allegedly maltreated:

First name (Vulnerable person)*

Last name*

Date of birth

Address*

User file Number

Medicare card number (RAMQ)

The person is under protective supervision or has legal representative with an homologated mandate.*

Yes

If yes, please specify the type of representation:

The person is a user of the establishment as defined in the Act to combat maltreatment of seniors and other persons of full age in vulnerable situations*

Yes

If yes, please specify - Program / facility / unit:

Name of the pivotal service provider or designated professional:*

3. Person suspected of maltreating:

First and last name (Person suspected of maltreating)

Adress

Phone

Age

Relation to the allegedly maltreated person:

Family member

Close circle

Person working for the establishment, or health and/or social service provider

Other

If working for the establishment…service provider – please specify (Full name and title)

The situation meets the requirements for mandatory reporting (Chapter 4 of the Act to combat maltreatment of seniors and other persons of full age in vulnerable situations)*

Yes

4. Description of the potential maltreatment:

Type of maltreatment*

Form of maltreatment*

Neglect

Violence

Has the person who is allegedly being maltreated, or their legal representative, consented to the disclosure of information?*

Yes

Please specify

Summary of the situation (e.g., chronology of events, signs of maltreatment)*

Do you have any other documents to add?

I agree that by typing my name, I am electronically signing this form*

Recaptcha*

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Initial maltreatment report form

Initial reporting of maltreatment

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