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Get CA Special Incident Report for All Vendors

__Male Vendor or Agency Name: Date of Report: If in Residential facility, date of admission: Service Coordinator: Conservator/Guardian name (if applicable): CCL Facility Number: Name of person reporting: Position at agency: _____Female E Fax: (213) 402-2906 TYPE OF INCIDENT (Check all that apply) Suspected Abuse/Exploitation (Limited to that which has occurred while under care/supervision of a vendor.) Check type: Sexual Fiduciary Emotional/Mental Physical and/or Chemical Restraint Ser.

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