INCIDENT REPORT
Program: ______Date of Incident: ______Time of Incident: ______AM / PM
Client Name: ______Gender: ____ Age: ____ Admit Date: ______
Witnesses / Persons Involved & Roles: ______
Place Where Incident Occurred: ______
Caregiver Responsible at Time of Incident: ______
Home Name: ______Phone Number: ______
Physical Address: ______
Type of Incident:
Verbal Aggression Significant Behavior Disruption Death Physical Aggression Injury to Client Hospitalization medical
Destruction of Property Injury to Staff Hospitalization psychiatric
Containment Self injury non-suicidal Medical problem
School related problem Suicidal ideation Medication error
Sexual behavior Suicidal gesture Medication refused
Substance abuse Suicide attempt Allegations: abuse/neglect
Criminal behavior Short personal restraint Incarceration
Other (please specify):
RunawayTime left: AM / PM Time/Date returned: AM / PM
PREPARED BY (signature) / TITLE / DATE COMPLETED
SUMMARY OF INCIDENT(For containments, skip this section and complete the containment report):
Detailed description of precipitating events or circumstances and specific behaviors that led to the emergency situation and if applicable, the specific behavior which continued to constitute an emergency situation:
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Summary of Incident (please be specific and state the facts of the incident):
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How was incident resolved?
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* Summary continued on additional page? _____ yes _____ no
Client Name: ______
Date: ______Time: ______AM / PM
Summary of Precautions:
Suicide:Date: ______Time: ______AM / PM
Runaway:Date: ______Time: ______AM / PM
AggressionDate: ______Time: ______AM / PM
Sexual Acting Out:Date: ______Time: ______AM / PM
Other:Date: ______Time: ______AM / PM
Date/Time of Actions Taken:
Medical TreatmentDate: ______Time: ______AM / PM
Name of Treating Physician: ______
Doctor’s Instructions for Follow Up: ______
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First Aid AdministeredDate:______Time: ______AM / PM
Short Personal RestraintDate:______Duration: ______(must last less than 60 seconds)
Protection from external danger (i.e. entering street, hot stove, separating children from physical altercations)
Child <5 yo Disruptive Behavior (other efforts have failed)
Child >5 yo Safety Risk (i.e. disrobing, provoking, fighting)
Notifications: DaTe Time(circle AM or PM) Name of Person Contacted
On Call Staff ______AM / PM ______
Supervisor/CaseManager ______AM / PM ______
Police / Rpt #______AM / PM ______
TDFPS/JPD/TYC ______AM / PM ______
Parent/Conservator ______AM / PM ______
TDFPS Hotline / Rpt #______AM / PM ______
Other ______AM / PM ______
ADMINISTRATIVE USE ONLY:
Reportable: Non-Reportable:
Operation ID: Assessment 520244 GRO 030031 CPA 209976
Level of Care: Basic Moderate Specialized
Service Level: Child Care Services Treatment Services
Review, Recommendations, and Comments
on “Critical” Incidents (if indicated)
Title of Staff Person: Case Manager/Caseworker:______
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Signature: ______Date: ______
Title of Staff Person: Unit/Foster Care Supervisor:______
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Signature: ______Date: ______
Title of Staff Person: Program Director:______
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Signature: ______Date: ______
Title of Staff Person: Administrator:______
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Signature: ______Date: ______
Title of Staff Person: ______
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Signature: ______Date: ______
IR (9/24/2013)- 1 -