Foster Care Services

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FOSTER CARE SERVICES

INCIDENT REPORT

When this form is being used, the FCS 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: ______Location of Incident: ______

Date of Incident: ______Time of Incident: ______AM PM

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*

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Other

/ Urine / Feces
/

Child Reported Incident*

/ / Blood / Saliva

Signature of Care Giver/FCS Staff Completing report:______Date:______

Signature of Witness, if applicable:______Date:______

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Child Review/Comment: This incident report is:_____accurate______inaccurate.

Comments:______

Signature of Child:______Date:______

Report should be forwarded within 24 hours to Case Manager. Feb 2017