Certified Investigation Report

Case: [Enter Case Name Here] Case #:[Enter Case # Here]

CI: [Enter CI Name Here]Date of Report:[Enter Date of Report Here]

I. Introduction
1. Indicatethe date andtime the incident allegedly occurred,if known.
[Type Here]
2. Indicatetimethe incidentwasreportedtofacilitypersonnel.
[Type Here]
3. List name(s)of the person(s)reportingthe incident.
[Type Here]
4. Indicatedate andtime the investigatorwasassignedthe case.
[Type Here]
5. Statethenatureof theallegation(orreasonforthe investigation), andinformationprovidedtotheinvestigatoratthetimeofassignment.
[Type Here]

II. Investigative Methodology

A. General Information
1. List thedate(s)andtime(s) the investigator visitedthe site of theincident.
[Type Here]
2. Listtheperson(s)withwhomtheCIspoke withat that sitetoassess initialresponsestopreservingevidence aswellasissuesandneedsoftheinvestigation.
[Type Here]

B. Collecting Physical and Demonstrative Evidence

1. Describehowtheincidentscenewassecured(if itwasn’tsecuredexplainwhy).
[Type Here]
2. Listeachpiece ofphysicalevidenceidentifiedandlogged.
[Type Here]
3. Listeachpiece ofphysicalevidencecollected.
[Type Here]
4. Chronologically list (by date,time,description andname ofpersontakingphoto)anyphotographsorvideostaken.
[Type Here]
5. List(by dateandtime)allotherdemonstrative evidence available totheinvestigation,e.g.diagrams,maps,floorplans,x-rays,etc.
[Type Here]
6. Describe howthephysicalanddemonstrativeevidencewaskeptaftercollectioninordertomaintainthechainofcustody.
[Type Here]

C. Collecting Testimonial Evidence

1. Brieflydescribehowpotentialwitnesseswereidentified.
[Type Here]
2. Chronologicallylistallwitnessesinterviewed.Includetitle,dateandtimeofeachinterview.
[Type Here]
3. Name theperson(s),if any,asthe target(s)oftheinvestigation.
[Type Here]
4. Ifthe righttorepresentationexistsbylaw,regulationorlaborcontract,describe howtheallegedtarget(s)orother witnesseswereaffordedthis right.
[Type Here]

D. Collecting Documentary Evidence

1. List writtenstatementstakenfromindividualsinterviewed duringthe investigation.If identicaltoII.C.2.above, simply referencethat here.Ifnotcreate achronological list notingname, date,and time statement wasprepared foralldocumentsconsidered“witnessstatements.”
[Type Here]
2. Listallotherdocumentscollectedinthe case(businessrecordsof theorganization,etc.).
[Type Here]
3. Describehowbusinessrecordscollected asevidence weresecuredpriorto,andafter,collection.
[Type Here]

III. Evidence Summary

1. Listthe investigatory question(s)needingto beansweredby theinvestigation(if multiplequestionsmustbeanswered, listeachoneseparately).
[Type Here]
2. List alldirectevidence available toanswerthe investigatory question(s).
[Type Here]
3. List allcircumstantialevidence available toanswerthe investigatoryquestion(s).
[Type Here]
IV. Certified Investigator’s Initial Analysis of Evidence
Foreachinvestigatory questionidentifiedinthe EvidenceSummaryabove, prepareanarrativeanalysis of theinitialreconciliationofevidence andthe reasonsforthe conclusionsbeing drawn.
Analysisoftheevidenceandreasonsfortheconclusionsofevidencepresented:
[Type here]
V. Administrative Review, Findings, Recommendations, and Implementation
1. Was the incident reported in a timely manner? Yes No (Circle One)
If No,pleaseexplain here. (ANDenteryourcorrectiveaction plan in Implementation section below.)
[Type here]
2. What actions were taken immediately to protect the health and safety of the individual?
List actions here. If none were taken, please explain here. (AND enter your corrective action plan in implementation section below.)
[Type here]
2a. Was victim assistance offered when appropriate? Yes No NA (Circle One)
If yes, what assistance was offered? If no, please explain here. (AND enter your corrective action plan in Implementation section below.)
[Type here]
3. If the incident involved a target, was the alleged target(s) removed from potential contact with all individuals receiving services until the incident investigation is completed?
Yes No NA (Circle One)
If yes, enter date and time personnel action occurred: [Type here]
If no, explain here. (AND enter your corrective action plan in Implementation section below.)
[Type here]
4. Were there injuries to the individual that required medical attention?
Yes No (Circle One)
Enter date and time injury discovered: [Type here]
4a. If yes, was prompt medical attention provided? Yes No NA (Circle One)
*If no, a neglect incident may have to be filed and corrective action in response to the delay in treatment needs to be present in the report.
If no, please explain. (And enter your corrective action plain in Implementation section below.)
[Type Here]
4b. Is follow up medical treatment recommended? Yes No (Circle One)
If yes, date and time of scheduled follow up appointment(s): [Type here]
5. Did the investigation start in a timely manner? Yes No (Circle One)
If no, please explain. (AND enter your corrective action plan in Implementation section below.)
[Type here]
6. Was the family notified of the incident within 24 hours? Yes No NA (Circle One)
If no, please explain. (AND enter your corrective action plan in Implementation section below if family should have been notified.) [Type here]
6a. When appropriate werenotification requirementsrelating tothe Adult Protective Services Act,OlderAdultProtectiveServicesAct and Child ProtectiveServicesLaw met?
Yes No NA (Circle One)
If no, please explain. (AND enter your corrective action plan in Implementation section below.) [Type here]
6b. If there was reason to suspect that a crime had been committed, was law enforcement notified?
Yes No NA (Circle One)
If no, please explain. (AND enter your corrective action plan in Implementation section below.) [Type here]
7. Did theevidencecollectedand presentedinthereportbytheinvestigatorsupport their analysis?
Yes No (Circle One)
Please explain why you believe the evidence collected and presented did or did not support the investigator’s analysis.
[Type here]
8. Did theevidencesupport adetermination thatabuseor neglectoccurred?
Yes No (Circle One)
If yes, explain. (AND enter your corrective action plan in Implementation section below.)
[Type here]
9. Werethereviolationsof agencyor facility policyinvolved in thisincident?
Yes No (Circle One)
If yes, explain. (AND enter your corrective action plan in Implementation section below.)
[Type here]
10. Review Status: To Be Continued Closed (Circle One)
If to be continued, due date: [Type here]
11. Administrative Findings: Confirmed Not Confirmed Inconclusive (Circle One)
Explain final analysis of evidence supporting Administrative Finding. [Type here]

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Certified Investigation Report

Case: [Enter Case Name Here] Case #:[Enter Case # Here]

CI: [Enter CI Name Here]Date of Report:[Enter Date of Report Here]

Implementation
12. Werethereany issuesorconcernsidentified inthe investigationthatwould lead to changes in individual(s)care, modifications to the individual support plan personnel,orotheradministrativeand systemicpractices?
If no, explain.
[Type here]
Ifyes,usethetemplatebelowto create an action plan.Includeinformationon whatactivities aretobecompleted,whois responsibleforcompletingthem,a targetdateforcompletion,andthedatethe action iscompleted (if known at time of completion of report).
Action / FunctionalArea(e.g.Fiscal,ProgramServices,Personnel,etc.) / Person(s)andPosition(s)Responsible / TargetDate / Status
Reviewer Name and Title / Signature

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