Sensitive Issue Report

Date of Sensitive Issue Report:      

Distribution list: In Outlook: CW-Sensitive Issue Report Distribution at
CAF-SensitiveIssue@dhsoha.state.or.us
Distribution list for Employee Sensitive issues: in Outlook: Employee Sensitive Issue at
Employee.SensitiveIssue@dhsoha.state.or.us

District manager:      

District/county:      
Child Welfare Program manager:      
Supervisor name:       Phone:      
Local office:      
Case worker:       Phone:      
Form completed by:       Phone:      
Reason for sensitive issue (check all that apply):
Child fatality Alleged provider/employee misconduct Media attention
Other (explain):      
Involved persons:
Name D.O.B. Case number/ Role/person number Child
(first name, last name) (mm/dd/yy) provider number victim
                       
                       
                       
                       
                       
                       
                       
                       
1. Case currently open: CW: Yes No SS: Yes No
 Was a Child Welfare case/assessment opened prior to the incident? Yes No
 If yes, date case/assessment opened:      
 Was the affected child(ren) in the custody of the Department? Yes No N/A
2. Date of incident:      
3. Details of incident:      
4. Recent referrals/contacts with family/children, if any:      
5. Action taken/planned:      
6. Trauma response assistance/resources requested? Yes No
7. Central office assistance requested:      

DHS 0150 (11/19) Page 1 of 2

8. For further questions please contact:      

Distribution list: In Outlook: CW-Sensitive Issue Report Distribution at

CAF-SensitiveIssue@dhsoha.state.or.us
Distribution list for Employee Sensitive issues: in Outlook: Employee Sensitive Issue at
Employee.SensitiveIssue@dhsoha.state.or.us

Send sensitive issue reports to the distribution list (above), also include the District
Manager and Program Manager.
In situations involving multiple districts, include the District Manager and Program
Manager in each district.
Send Sensitive Issue Reports regarding DHS employees to the distribution list above.

Central Office Administration use only — decision documentation

Should this incident be recommended for CIRT?
Yes, mandatory per statute:      
Yes, discretionary:      
No:      
Decision still pending:      
Further action:      
Determination review:      

Reason(s) for decision:      

Date:      
Individuals involved in decision:      

DHS 0150 (11/19) Page 2 of 2