INCIDENT REPORT

POL PROC Forms\Forms\PRO\RES CC\ INCD RPT Form

Program: / Boys Ranch / Girls Ranch / Pippin Ranch
Resident’s Name:
Staff Person Completing Report:
Start Date: / End Date: / Start Time*: / End Time*:

*Please include am, noon, pm or midnight

X / Incident Events /

X

/ Incident Events
1. Contacts
/
6. Suicide
Police Contact / Suicide Ideation
Family/Agency Contact / Suicide Attempt
Child Protective Service Contact / Non-Specific Suicidal Behavior
2. Medical/Psychiatric Care / Self Destructive Behavior
Mental Health Service / 7. Illicit Drug Use
Injury / Substance Abuse (alcohol)
Outpatient Medical Care / Substance Abuse (marijuana)
3. Medication / Substance Abuse (other)
Medication error wrong medication / 8. Positive Incident
Medication error staff / Resolved conflict peacefully
Medication refusal
/ Exercises self control
Skipped medication / Provided assistance to staff or resident

Other positive incidents

4. Behavioral Concerns
/

9. School Behavior Problems (SCH)

Runaway / Non-Cooperative Behavior (School)
Non-Cooperative Behavior (Non-School) / School Referral
Physical Assault on Staff / Physical Assault on Staff
Physical Assault on Youth / Physical Assault on Youth
Property Damage / Property Damage
Theft / Theft
Restraining Youth / Restraining Youth
Bullying / Bullying
Verbal/Symbolic Aggression / Verbal/Symbolic Aggression
Physical Aggression / Physical Aggression
Noteworthy Inappropriate Behavior / Skipping School
5. Sexualized Behavior
/ Noteworthy Inappropriate Behavior
Sexual Assault – Perpetrator / In-school suspension
Sexual Misconduct / Out of school suspension
Sexually Exploitive Behavior / Expelled

Each staff member observing the interaction should write their description of the incident in the area provided below this box. Description of the incident should include what, when, where, and how. Include what led up to this incident. Include staff name after each comment and date the report was written.

Incident:

Action taken:

Names of people notified about incident:

Aviator Example: Smith Joe A INCD RPT 10.15.02 Physical Assault on Staff

School Example: Smith Joe A INCD RPT 10.15.02 SCH Property Damage