State of Maryland Department of Health and Mental Hygiene – BEHAVIORAL HEALTH ADMINISTRATION Catonsville, MD 21228 NOTIFICATION OF ALLEGATION OF SEXUAL ASSAULT/HARASSMENT OF AN INDIVIDUAL Name of Alleged Victim: Gender: Age: Address: Type of Service: Location of incident: If inpatient facility, name of facility: Unit: If community or other program, name of program: Address of program: Name of program director: Telephone: Date & time of incident: Type of incident: Describe the circumstances of the incident. (Attach additional pages as needed): What supports have been offered to the alleged victim? Was incident reported to a local law enforcement agency? Yes No If Officer’s name: Jurisdiction: Report # ‘yes’, If reason: Reported to administrative head of facility ‘no’, Reported to facility police Reported to Child Protective Services If alleged abuse occurred in a community-based mental health program or BHA-operated facility: Report (oral) was made to (required): Facility or Program name: Date & time: – OHCQ Staff name: Date & time: –
State of Maryland – Department of Health and Mental Hygiene BEHAVIORAL HEALTH ADMINISTRATION Catonsville, MD 21228 NOTIFICATION OF ALLEGATION OF SEXUAL ASSAULT/HARASSMENT OF AN INDIVIDUAL Name of Alleged Victim: Gender: Age: Address: Type of Service: Location of incident: If inpatient facility, name of facility: Unit: If community or other program, name of program: Address of program: Name of program director: Telephone: Date & time of incident: Type of incident: Describe the circumstances of the incident. (Attach additional pages as needed): What supports have been offered to the alleged victim? Was incident reported to a local law enforcement agency? Yes No If ‘yes’, Officer’s name: Jurisdiction: Report # If ‘no’, reason: Reported to administrative head of facility Reported to facility police Reported to Child Protective Services If alleged abuse occurred in a community-based mental health program or BHA-operated facility: Report (oral) was made to (required): Facility or Program – name: Date & time: OHCQ – Staff name: Date & time:
DHMH_4749%20Notification%20of%20Allegation%20of%20Sexual%20Assault%20Harassment%203-27-2017%20(1).docx