Free Form 02AG047E - Oklahoma

*02AG047E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Recruitment Incident Report

Complaint information
Name of person making complaint Agency name of person making complaint Title Date of Incident Phone

Members involved
Name Date of birth Case number Medicaid ID number

Details
Describe what happened from beginning to end of incident, including all details and who, what, when, where, how, and why. Use additional pages as needed.

Please attach any evidence to support allegations.
Signature of person making complaint Signature of agency owner or administrator Title Title Date Date

Issued 5-1-2009

02AG047E

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02AG047E Purpose of form

Recruitment Incident Report

This form is used by an ADvantage provider to file a complaint alleging a specific recruitment violation. Instructions

Complainant information: The ADvantage provider alleging an incident completes
this section.

Members involved: The ADvantage provider completes this section documenting all ADvantage members involved in the specific incident. Details: The ADvantage provider completes this section documenting all important
details relating to a specific incident. Only use this form if you have evidence or witnesses to substantiate the allegation. Evidence can be in the form of testimony or physical documents. If evidence is testimonial in nature, please use proper names, titles, and dates of when specific conversations occurred and what was said. Include phone numbers of witnesses so they can be contacted. Be specific as possible in this section. Ensure all physical evidence is attached to the form when submitted. Routing Original to OKDHS Aging Services Division, 2401 NW 23rd Street, Suite 40, Oklahoma City, OK 73107 Deadline This form must be returned to OKDHS/ASD within ten business days of the recruitment incident.

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Issued 5-1-2009