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Get OH DMHAS-0484 2018-2024

Te Submitted to OhioMHAS: Date of Discovery: Date of Incident: Provider Name: Print Form Time of Incident: Provider Number: Provider Address (street, city, state, zip): Name of Provider Contact: Phone Number: Contact E-mail Address: Name of Person Completing Report, if different than Provider Contact: Notifications Made: ADAMH/CMH Board (list names): Children Services Board OhioMHAS Family/Guardian Other Protective Agency Abuse and Neglect by Staff (including allegations): Physical.

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