Yearly Report Submission to DPH FLIS Page

Attention Hospital Providers – STOP!! Please do not submit Hospital Staffing here!
Log into the FLIS Portal and use the “Hospital Staffing Reporting” tab to submit all Hospital Staffing Plans, Complaint Form template and Hospital Staffing Objection/Refusal Form template.
Please submit a ticket by clicking If you need assistance with user registration or login credentials for hospital staffing planning submissions, click the URL (https://dph-cthelpdesk.ct.gov/Ticket) and submit a ticket.

Submission Type

Facility Type

Facility Name

Facility License Number

*(ex. CCNH.01234567)

Telephone Number

Has any workplace violence occurred in the previous calendar year?

Yes No

Has any workplace violence or abuse occurred in the previous calendar year?

Yes No *

IF YES, select all that apply

Physical Abuse by agency client to staff member

Sexual Abuse by client to staff member

Verbal Abuse by client that is perceived as a threat by a staff member

Any Other Abuse by an agency client againest a staff member

Answer the above question only for Yearly Workplace Violence Submission

Submitted By

Submission Year(YYYY)