Welcome to the incident and monthly data reporting portal. This is a secure website that regional center vendors may use to submit incident reports and data reports required by law to be reported to Disability Rights California.

Vendor Report Form

Reports must be submitted no later than close of business the day following the incident.

Vendor/Facility Name:

Vendor/Facility Address:

Vendor/Facility Category

Report Prepared By:

Contact Number:

E-mail Address:

Event Details

Event Date

Event Type

1. Allegation of sexual assault of a resident involving staff

2. Allegation of physical abuse of resident by staff, reported to local law enforcement

3. Serious injury occurring during or related to restraint or seclusion

4. Resident death occurring during or related to restraint or seclusion

5. Resident unexpected or suspicious death NOT related to restraint or seclusion

Description of Event: