DHS Hotline Form

What is your relationship to the MN Department of Human Services? (Required)*

Your First and Last Name (Required)*

Your E-mail and/or Phone Number (Required)*

What business area/division do you work in and where is your work location? (Optional)

Date and Time of Incident (Optional)

Name(s) of persons involved in the incident being reported (please separate each name by a comma) (Required)*

Person Involved (Check all that applies) (Optional)
DHS Employee Client/Recipient Contractor/Third Party/Vendor External Partner/Community Member Other

Please identify the administration involved:*

If you reported this incident to another agency, give the name of the agency

Location of Occurrence (If Applicable) (Optional)

Description*
Tenant 22

DHS’ goal is to use these reports to improve internal controls, systems and process. To accomplish this, DHS needs to thoroughly understand your concern.

Please describe your concern in detail including:
• how the situation or incident happened including any contributing factors or relevant context;
• how it was discovered;
• any remediation efforts that have occurred; and
• anything else you feel is important.

Please do not use acronyms.

Incident Description

The Compliance Office may contact you for additional or clarifying information including for supporting documentation. If you do not provide complete information, Compliance Office may not have enough information to continue its investigation and may close the case.

By submitting this form, you acknowledge that you read the Tennessen Warning, and all the information you provide on this form is accurate to the best of your knowledge.

For questions or concerns, contact 1-800-664-3590 or email the DHS Compliance Office at DHS.Compliance.Hotline.DHS@state.mn.us.

**Clicking the submit button more than once could result in duplicate submissions of the record**

Application Type

Hidden Fields

Subject*

From Address*

From name*

Do you wish to remain anonymous for this report?
Yes No

First Name (Person Involved)

DHS requires that reporters leave their name and contact information when filing a report on this hotline. We will contact you using the information below to confirm your submission and may ask for additional or clarifying information. For information on your data privacy, please see the Tennessen Warning section below.

This hotline is managed by the DHS Compliance Office. If the concerns reported are within another business area or agency’s responsibility, your concern and contact information may be shared with an appropriate contact, for example, Human Resources Director or Equal Opportunity and Access Division (EOAD) Director.

Thank you for taking the time to complete this form to report your concerns.

If this is an emergency, call 911 and/or the DHS security officers at (651) 431-3000, as appropriate.

To read about a policy, click its link below

This form asks you to give some information about yourself that is considered private or confidential under the Minnesota Government Data Practices Act (Minnesota Statutes Chapter 13). The Minnesota Department of Human Services (DHS) is collecting this information to understand and investigate your concern. You are not legally required to provide information on this form, but if you do not provide information you may fail to comply with DHS policies, and may be subject to discipline, up to and including termination. If you don't provide this information, DHS may not be able to investigate your concern or get all of the information needed to complete the investigation. The information that you give may be used to take disciplinary or other remedial action, and you may be required to testify at a hearing about that information. The information you provide may be shared with: the subject(s) of the report; DHS employees whose work assignments reasonably require access including, but not limited to, the DHS Ethics Office, Office of Internal Controls and Accountability, Human Resources, the report subject(s)’ supervisor(s) or manager(s), and your supervisor or manager; the State or Legislative Auditor; the Bureau of Criminal Apprehension; the Attorney General; Minnesota Management and Budget; law enforcement agencies with statutory authority; and/or any other person or entity authorized by state or federal law or court order to access the data.