Child S Name: Date of Birth: County: Male Female

LSS Foster Care

INCIDENT REPORT

(When this form is being used, the Foster Care on-call staff or Supervisor MUST be notified by calling the crisis number.)

Child’s Name: Date of Birth: County: Male Female

Date of Report: Foster Home:

Date of Incident: Time of Incident: AM PM Location of Incident:

1. Detailed Description of Incident: (Include who, when, what, where, how; Include what led up to the incident, the incident and follow up)

2. Summarize Prevention & Intervention Strategies Used Prior To and After Incident: (Strategies used to prevent incident and child’s reaction; describe efforts in increase supervision and resolve situation.)

3. Outcome and Response: (Describe outcome of incident, status of youth-child’s feelings, reactions, attitudes, behaviors observed, anger, rage, sullen, despondence, compliance, etc. If a physical intervention (i.e. physical escort or passive physical restraint) was initiated identify the SPECIFIC “dangerous” behavior that warranted the physical intervention)

4. Report of Physical Injuries:

5. Medical Attention Given:

6. Case Manager/On-call staff was called/involved No Yes If yes, who:

7. Contacts Made (The following contacts were authorized by a Supervisor/Case Manager/On- Call. Include name, date, and time)

Law Enforcement Agency:
Health Care Provider:
Other:

Required External Reports

Noncompliance

Illegal Conduct

Interventions

Neglect* / Significant Disruption / Physical Assault/Aggression* / Verbal Redirection
Physical Abuse* / Verbal Aggression / Dangerous Behavior* / 1:1 Processing
Sexual Acting Out* / Threatening Behavior* / Property Destruction* / Time Out Given
Sexual Abuse* / Inappropriate Sexual Comments / Attempted / Room Search
Suicidal Gestures* / Inappropriate Sexual Behavior* / Actual / Police Report Filed
Reported Past Abuse* / Left Without Permission* / Drug Possession/Use*
Runaway* / Tobacco Related / / Weapon Possession* / Child Physically Restrained
Psychiatric Hospitalization* / Gang Related / Theft* / 1. Danger to Self
Medical Hospitalization* / Interfering in a Crisis* /

Medical

/ 2. Danger to Others

Emergency Medical Care*

/ Noncompliance / Injury – Self Harm* / 3. Restraint Length:
Victim of Assault / / Grooming - Sexual / Injury – Accidental

High Risk Watch

/ / Grooming – Nonsexual / Basic First Aid
Potential Runaway Behavior* / / Power Thrusting/Intimidation / Blood Borne Pathogen* / *=May require external report
/

Potential Self Harm Behavior*

Other

/ Urine / Feces
/

Child Reported Incident*

/ / Blood / Saliva

Signature of Care Giver/TFC Staff Completing report: Date:

Signature of Witness, if applicable: Date:

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