DODD-Online Complaint Form

Report your concern about abuse, neglect or theft happening to a person with developmental disabilities

1. If someone is in danger, don’t wait! Call local law enforcement now.

2. The fastest way to report your concern is to contact your county board of developmental disabilities’ MUI Reporting Hotline.

3. Use this online reporting form to report a concern or call the DODD Abuse and Neglect Hotline during business hours at 1-800-617-6733 option #1.

Bold fields are required.

Please correct the following errors

Section 1- (Optional)

Person reporting abuse/neglect

You can complete only if you wish to receive acknowledgement of your complaint.

If you would like to remain anonymous, please select Yes in the radio button.

Would you like to remain anonymous? Yes No

First Name

Last Name

Relationship

Street Address

City

State

Zip

Primary Phone

Alternative Phone

Section 2 - (Required)

Victim(s) information

Individual(s) with Developmental Disabilities involved in the complaint.

The Individual affected first/last name and county are required fields.

Individual affected first name (Please enter NA if you don't know.)

Individual affected last name (Please enter NA if you don't know.)

County/Developmental Center where individual/person resides

Enter the county or developmental center where the individual/person resides.

Street Address

City

State

Zip

Additional Name(s)

Section 3 - (Required)

Incident witnessed

Description of the Incident witnessed (Who, What, Where, When, How and Why). Please include details, duration, etc. You may include an attachment.
The Incident Type and Description are required fields.

Incident type

Incident type details (field is only applicable if Other chosen)

Incident date

Incident time

Incident location

Description Must be 500 characters or less

Attachment Accepted Formats Include:JPG/JPEG/GIF/PDF/Word Document files

Others notified of your complaint

Agency name and/or person contacted.

Agency Contacted

Person Contacted

Section 4 - (Optional)

Alleged Perpetrator/Primary Person Involved

Name of person/agency you are filing complaint about.

If this information is not available, please select No in the radio button.

Do you know any person/agency information you are filing complaint about?
Yes No

Person first name

Person last name

Title

Agency Name

Street Address

City

State

Zip

Phone

Section 5 - (Required)

Provider Information

Person and/or company providing services to individual.

If this information is not available, please select No in the radio button.
Correct Verification Words are required to submit the entry.

Do you know any provider information? Yes No

Agency Provider Name

Provider first name

Provider last name

Is the individual still being served by this provider?

Street Address

City

State

Zip

Phone

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