Abuse report form

Please complete the form to the best of your knowledge.

Signalement

Mandatory reporting
Voluntary reporting (authorized by the user)

1. Identification

Reporting person

Are you employed at the CISSS de l’Outaouais? *

Yes
No

First name *

Last name *

Date of the event

Reporting date *

Alleged mistreated person

First name

Last name

Date of birth

File number

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’ residence

CHSLD

RI-RTF

RPA

Other

Alleged abuser(s)

First name

Last name

Relationship with user *

Ajouter une autre personne1

Add another person

Second alleged abuser(s)

Third alleged abuser

2. Type of potential mistreatment (check corresponding box(es))

Type(s) : *

3. Factual and detailed description of the event/impacts (chronology of the facts, indications of mistreatment and witnesses present if applicable)

Date

Factual, objective and detailed description of the event
(observable and measurable facts)

Date - DESCRIPTION DE L’ÉVÉNEMENT 1

Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 1

Date - DESCRIPTION DE L’ÉVÉNEMENT 2

Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 2

Date - DESCRIPTION DE L’ÉVÉNEMENT 3

Paragraphe - DESCRIPTION DE L’ÉVÉNEMENT 3

4. Actions taken to manage the situation of mistreatment

MANDATORY: Actions planned/completed by the team / Description of each action to avoid recurrence

Action 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.

5. Checklist

Aide-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?

of if to

Event number *

6. Consent

The 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? *

Yes
No

7. Documentation

Do you have any documents or other supporting documentation? *

Yes
No

Please send it to : commissairesauxplaintes@ssss.gouv.qc.ca

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