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A Division of the Maine Department of Health and Human Services
DHHS → DLC Home → Reportable Incident Form
Complaint Line: 207-287-9308
Fax Line: 207-287-9307
Full Names, Unit, Room Number
Include any staff present at the time of the incident:
Full Names, Title/Relationship, Phone Number
If staff members are listed, please indicate their status of employment, ex.; suspended/working/leave/etc.
Full Name, Title/Relationship, Phone, Employment Status
Please include how & why and if this incident has occurred before:
Check any that apply.
Please describe in full below:
Describe in detail below:
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