Download Incident Report

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 Report:
Date of Incident:
Date of Birth:
County:
Male
Female
Foster Home:
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
Neglect*
Physical Abuse*
Sexual Acting Out*
Sexual Abuse*
Suicidal Gestures*
Reported Past Abuse*
Runaway*
Psychiatric Hospitalization*
Medical Hospitalization*
Emergency Medical Care*
Victim of Assault
High Risk Watch
Potential Runaway Behavior*
Potential Self Harm Behavior*
Noncompliance
Illegal Conduct
Significant Disruption
Physical Assault/Aggression*
Verbal Aggression
Dangerous Behavior*
Threatening Behavior*
Property Destruction*
Inappropriate Sexual Comments
Attempted
Inappropriate Sexual Behavior*
Actual
Left Without Permission*
Drug Possession/Use*
Tobacco Related
Weapon Possession*
Gang Related
Theft*
Interfering in a Crisis*
Medical
Noncompliance
Injury – Self Harm*
Grooming - Sexual
Injury – Accidental
Grooming – Nonsexual
Basic First Aid
Power Thrusting/Intimidation
Blood Borne Pathogen*
Other
Urine
Feces
Child Reported Incident*
Blood
Saliva
Interventions
Verbal Redirection
1:1 Processing
Time Out Given
Room Search
Police Report Filed
Child Physically Restrained
1. Danger to Self
2. Danger to Others
3. Restraint Length:
*=May require external report
Signature of Care Giver/TFC Staff Completing report:
Date:
Signature of Witness, if applicable:
Date:
*****************************************************************************************************
Child Review/Comment:
This incident report is:
accurate
inaccurate.
Other Comments:
Signature of Child:____________________________________________________________
Report must be sent to LSS Case Manager within 24 hours of the incident.
Rev. Feb 2017
Date:________________