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INCIDENT REPORT
INCIDENT REPORT
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DATE/TIME OF INCIDENT
*
Date
Time
STAFF COMPLETING THE REPORT
*
First
Last
OTHER STAFF PRESENT
WHERE DID THE INCIDENT OCCUR?
*
RESIDENT(S) INVOLVED
*
NATURE OF THE INCIDENT
*
Abuse & Neglect
Allegations
Death
Defiance
Emergency
Hospitalization
Injury
Medical Emergency
Medication Incident
Misconduct
Overdose
Physical Aggression
Restraint/Seclusion
Runaway/Out of Bounds
Self-Harm
Sexual Assault
Substance Abuse
Suicide
Theft
Verbal Aggression
Unauthorized Weapons/Dangerous Items
Biohazardous Accident/Body Fluid Exposure
Communicable Disease/Infection Control
INDICATE THE DURATION OF RESTRAINT OR SECLUSION
*
WHO PROCESSED WITH THE YOUTH AFTER THE INCIDENT?
Direct Care Staff
Leadership
Therapist
Caseworker/Guardian
Other
WHO PROCESSED WITH THE YOUTH?
WAS THE RESIDENT INJURED, HARMED OR IMPACTED BY THE RESTRAINT OR SECLUSION?
*
WHAT TYPE OF ALLEGATIONS WERE MADE?
*
Abuse of Resident
Neglect of Resident
Sexual Abuse
Criminal Activity
Sexual Activity
Exploitation
Harassment
WHAT FORM OF PHYSICAL AGGRESSION OCCURED?
*
Property Destruction
Assault/Fight
Minor Offense (hitting, punching walls, etc)
Other
WHO WAS INJURED?
*
Resident
Staff
Visitor
THE INJURY REQUIRED THE FOLLOWING:
*
Off-Site Medical Care
First Aid-Care
No Care
WHAT TYPE OF MEDICATION INCIDENT?
Adverse Medication Reaction
Medication Error
Physician Order Error
WHAT TYPE OF DEATH?
Unexpected
Natural
Accidental
WHAT TYPE OF EMERGENCY OCCURRED?
Vehicle Accident
Fire
Natural Disasters
Bomb Threat
Power Failure
INDICATE WHICH OCCURED
Self-Harm
Suicide
Suicide Attempt
Suicidal Ideation (thinking about or planning suicide)
TIME OUT
*
TIME YOUTH RETURNED
DESCRIBE WHAT TOOK PLACE BEFORE THE INCIDENT.
*
WRITE A DETAILED SUMMARY OF THE INCIDENT: (Facts Only)
*
SUBMIT EVIDENCE (Photos, Documents, Etc.)
Click or drag a file to this area to upload.
WAS LEADERSHIP CONTACTED?
*
Yes
No
TIME
*
STAFF CONTACTED
Michelle
Sheldon
Kandace
Other
WERE THE POLICE CONTACTED?
*
Yes
No
TIME
*
CASE REPORT NUMBER (if available)
WHAT WERE THE CONSEQUENCES?
*
Warning
Time in Room
Loss of Privileges
Time on Restriction
Other
Does Not Apply
WHAT CONSEQUENCES WERE GIVEN?
*
HOW MANY DEDUCTIONS WERE GIVEN?
WHAT STRATEGIES WERE USED TO SOLVE THE PROBLEM?
*
Separation from Peers
One on One Talk with Staff
Time in Room to Cool Down
Redirection/Intervention
Contacted Leadership
Medical Attention
Stepping Out for Air
Other
Does Not Apply
WHAT STRATEGY WAS USED TO SOLVE THE PROBLEM?
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