APPLY FOR BENEFITS

Kevin S. Settlement
Keep Your Benefits NM
new mexico human services department logo

ABUSE, NEGLECT AND EXPLOITATION OR REPORT OF DEATH FORM (SFY 2019)

Always notify DHI/IMB immediately concerning incidents for individuals receiving the Developmental Disabilities Waiver (DDW), DD Mi Via
Waiver, or Medically Fragile Waiver, Contact IMB On Call at 1-800-445-6242 and send A/N/E form within 24 hours.

To notify Child Protective Services of an incident involving a child, call: 1-800-797-3260
To notify Adult Protective Services of an elder or non-DD waiver adult call 1-866-654-3219

IMB ANE Reporting Form

SECTION 1 - INDIVIDUAL INFORMATION

Your Name:(Required)
Gender:(Required)
MM slash DD slash YYYY
Your Address:(Required)

How Can We Reach You?

We would love to chat with you. How can we get in touch?
Your Email Address:(Required)

SECTION 2 - DESCRIPTION OF INCIDENT

Report of Death:
Type of alleged incident:(Required)
MM slash DD slash YYYY
Time of Incident:(Required)
:
Were other individuals present?(Required)

Other People?

PLEASE DESCRIBE WHAT HAPPENED. BE SPECIFIC ABOUT WHO WAS THERE (by name) AND WHAT YOU SAW AND HEARD.

SECTION 3 - ADDITIONAL INFORMATION

Would you like to remain anonymous as the reporter of this incident?(Required)
Name

SECTION 4 - AGENCY/FACILITY INFORMATION

SECTION 5 - ADMINISTRATIVE INFORMATION

Check the applicable boxes:(Required)
DD PROGRAMS ONLY - Type of services received by the Individual(Required)
Was an Immediate Action and Safety Plan created?(Required)
Max. file size: 512 MB.

SECTION 6 - NOTIFICATION TO AGENCIES REQUIRED

Legal Guardian:(Required)
Guardian name:
MM slash DD slash YYYY
Time:
:
Address
Case Manager:(Required)
Case Manager name and Agency:
MM slash DD slash YYYY
Time:
:
Address
Consultant:(Required)
Name:
MM slash DD slash YYYY
Time:
:
Address

Person Completing Sections 3, 4, and 5:

Law Enforcement:

Medical Attention/Treatment:

SECTION 7 - SIGNATURE

Name(Required)
MM slash DD slash YYYY