Abuse report formPlease enable JavaScript in your browser to complete this form.Please complete the form to the best of your knowledge.SignalementMandatory reportingVoluntary reporting (authorized by the user)1. Identification Reporting person Are you employed at the CISSS de l’Outaouais? *YesNoIf yes, what is your job title? *If yes, which directorate do you work for? *CPQS – Service Quality and Complaints CommissionerDG – General DirectorateRLS Directorates – (local service network): Vallée-de-la-Gatineau, Pontiac, Collines and Vallée-de-la-Lièvre et Petite-NationDERUR – Education, Academic Relations and Research DirectorateDSI – Nursing DirectorateDSMP – Medical and Professional Services DirectorateDSMSSS – Multidisciplinary Health and Social Services DirectorateDYP – Director of Youth ProtectionDJ – Youth Programs DirectorateDSMD – Mental Health and Addiction Programs DirectorateDSADDR – Home Support, Disability and Rehabilitation DirectorateDSAPAH – Direction of Autonomy Support and Long Term Care Lodging for the ElderlyDSPU – Public Health DirectorateDQEPE – Quality, Evaluation, Performance and Ethics DirectorateDSTL – Technical Services and Logistics DirectorateDTBI – Biomedical and Information Technologies DirectorateDRH – Human Resources DirectorateDCRP – Communications and Partner Relations DirectorateDRF – Financial Resources DirectorateDPNH – New Hospital Project DirectorateTN – Digital TransformationFirst name *Last name *Date of the eventReporting date * Alleged mistreated person First nameLast nameDate of birthFile number 1 name Date Living environment (specify the name of the resource if applicable) CHSLD : Long-term care facility RI : Intermediate resource RTF : Family type resource RPA : Private seniors’ residenceCHSLDRI-RTFRPAOther Alleged abuser(s) First nameLast nameRelationship with user *---ResidentEmployeeFamilyAcquaintanceOtherSpecify *Job title, if employed: *Ajouter une autre personne1 Add another person Second alleged abuser(s) First nameLast nameRelationship with user *---ResidentEmployeeFamilyAcquaintanceOtherSpecifyAjouter une autre personne2Add another person Third alleged abuser First nameLast nameRelationship with user *---ResidentEmployeeFamilyAcquaintanceOtherSpecify2. Type of potential mistreatment (check corresponding box(es))Type(s) : *PhysicalPsychologicalViolation of rightsSexualAgeismOrganizationalMaterial or financial3. Factual and detailed description of the event/impacts (chronology of the facts, indications of mistreatment and witnesses present if applicable)DateFactual, objective and detailed description of the event (observable and measurable facts)Date - DESCRIPTION DE L’ÉVÉNEMENT 1Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 1Date - DESCRIPTION DE L’ÉVÉNEMENT 2Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 2Date - DESCRIPTION DE L’ÉVÉNEMENT 3Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 34. Actions taken to manage the situation of mistreatmentMANDATORY: Actions planned/completed by the team / Description of each action to avoid recurrenceAction 1 *Put in place a safety net (e.g., increase staff presence in the environment, involvement of the behavioural and psychological symptoms of dementia team (SCPD), steps taken to open a protection and representation measure, information provided to the user regarding help resources, transfer to another living environment, etc.).Type of support provided to the victim in accordance with the “Managing a situation of mistreatment” procedure.Check to see if other users are being or have been mistreated.Trigger a concerted intervention process (CIP) or other objective.Explain the safety net *Explain the type of support *Specify the triggering of a concerted intervention process *5. ChecklistAide-mémoire *Have you informed the legal representative, public trustee or family sponsor of the situation?If you are a resource person, did you notify and involve your manager and resource person from your directorate?Did you involve the designated resource person at your directorate for the CIP?Is an action plan in place to ensure the safety of the victim of mistreatment?Did you involve Labour Relations if the alleged person is an employee of the CISSS de l’Outaouais?Have you completed form AH-223, if applicable? (POL-049, p.3). If yes, indicate the event number:Did you complete an initial disclosure (Pro-008) if applicable?Event number *6. ConsentThe CPQS is responsible for ensuring the confidentiality of information that identifies the person who reports mistreatment unless the person has given consent.Do you consent to your identity being shared if necessary? *YesNoFirst name, last name *Job title *Date *7. DocumentationDo you have any documents or other supporting documentation? *YesNoPlease send it to : commissairesauxplaintes@ssss.gouv.qc.ca Send