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NYS OMH Incident Review Panel Submission Form

Incident Review Panel Request Information

Please submit your incident to be considered for the Incident Review Panel. Please include as much information and detail as you can. Requests submitted to OMH are reviewed consistent with Mental Hygiene Law § 31.37. OMH periodically issues public, deidentified cumulative reports consistent with statutory confidentiality requirements.

1. Today's Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. What is your name? *This question is required.

3. Please enter the best email address for us to contact you. *This question is required. This question requires a valid email address.

4. What is your role? *This question is required.

Advocate
County Mental Health Director
Direct Service Provider Agency
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

5. Enter your organization's name here:

6. Please indicate if the incident occurred in the community, if it involved a person with a serious mental illness and if it involved the use of deadly force and resulted in serious physical injury. These are all requirements for the incident to be considered for the Incident Review Panel. *This question is required.

Space Cell	Yes	No
Did the incident occur in the community?	Did the incident occur in the community?: Yes	Did the incident occur in the community?: No
Did the incident involve a person with a serious mental illness? (that suffered or caused one or more others to suffer)	Did the incident involve a person with a serious mental illness? (that suffered or caused one or more others to suffer): Yes	Did the incident involve a person with a serious mental illness? (that suffered or caused one or more others to suffer): No
Did the incident involve the use of deadly force and result in serious physical injury?	Did the incident involve the use of deadly force and result in serious physical injury?: Yes	Did the incident involve the use of deadly force and result in serious physical injury?: No

7. In what town, city or borough did the incident occur?

8. Do you know the name of the individual involved in the incident with a serious mental illness? *This question is required.

Please enter an 'other' value for this selection. * This question is required.

9. Do you know the DOB of this individual?

Please enter an 'other' value for this selection. * This question is required.

10. Enter the date of the incident, if you know it, here: This question requires a valid date format of MM/DD/YYYY.

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11. Describe the incident here: *This question is required.

12. Copy and paste any links to media reports regarding the incident here. (optional)

13. Enter any additional information you believe is relevant to your request. (optional)

14. Upload any files you believe are relevant to your request. (optional)

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