Abuse report form

Please complete the form to the best of your knowledge.

1. Identification

Reporting person

Alleged mistreated person

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

Alleged abuser(s)

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

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)

4. Actions taken to manage the situation of mistreatment

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

5. Checklist

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.

7. Documentation