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Incident Report Form
INSTRUCTIONS: An Incident Report shall be completed before the end of the shift in which an incident occurs. See 3A.- “Immediate Reportable Concerns” to document any use of force by staff on a child; destruction of property involving a child; medication problems; suspension or expulsion of a child from school; any fire; any involvement of a child with law enforcement authorities; any serious illness or injury; any abuse or neglect witnessed by staff, volunteers, or other children; when a child is moved to another unit to protect their safety or the safety of others; upon the death of a child; physical fights; sexual acting out; or alcohol abuse. See 4 “Other Reportable Concerns” to document. Please address all data fields. Do not leave fields blank; use “NA” if not applicable.
Incident Details
Incident Date
*
Date Format: MM slash DD slash YYYY
Incident Time
:
HH
MM
AM
PM
Incident Location
*
Clients / Employees Involved
Clients Involved
*
First Name
Last Name
Client ID #
Employees Involved
*
First Name
Last Name
Immediate Reportable Concerns
(CHECK ALL THAT APPLY; PHONE PLACING ENTITY)
Immediate Reportable Concerns
AWOL (Off Grounds)
Child Alleging Physical or Sexual Abuse / Neglect
School Expulsion / Suspension (formal action by school)
Involuntary Termination of Treatment w/o Informing Resident
Med TX—Hospital or ER
Illicit drug/alcohol use; Abuse of meds or toxic substance
Perp of Delinquent / Criminal Act/ Client Arrested
(Assault, Dangerous Bx, Homicidal Bx)
Medication Error Resulting in Hospitalization or Death
Death of Child
Self-Injury (Suicidal Bx, Self-Harm)
--Requiring external Med TX--
Hospital, ER
Victim of assault, neglect, Phys. or sex abuse
Medical or Natural Event Impacting Facility Operations Causing Movement of Residents
If Allegation of Abuse Were Made or Charges Were Filed:
Victim Name
Offender Name
OTHER REPORTABLE CONCERNS
Phone Parent/Guardian, DD SSA By End Of Shift
Concerns
Physical Aggression
Verbal Aggression
Minor Injury / Illness
Sexual Act
Unusual Other
Briefly Describe:
e.g., “Punching,” “Bullying,” “Vomiting,” “Public Undressing,” “Refuse to Wake up,” “Stealing,” “Automobile Accident,” etc.
INTERVENTIONS
(CHECK ALL THAT APPLY)
Interventions
Understanding Responses
Clarified Event
Remove the Target / Weapons
Eliciting Techniques
Mediated Situation
Playfulness (PACE)
Managed the environment
Gave Choices
Acceptance
Prompting
Dropped / Changed Expectations
Curiosity
Caring Gestures
Appealed to Self-Interest
Empathy
Hurdle Help
Offered Alternatives
Teaching Interaction
Redirection or Distraction
Gave Time to Decide
Guiding*
Proximity
Took Deep Breaths
Medical Intervention (OSY Nurse)
Directive Statements
Personal Protective Stance
Medical Intervention (EMS/ER/Urgent Care)
Time Away
Life Space Interview
Planned Ignoring
OTHER:
Other:
*Escorting a client must be documented on an OSY 460 Physical Restraint form. When during the use of “Guiding or Escorting,” a client drops to the floor the use of Guiding or Escorting is to be immediately terminated—dragging, pulling, or pushing is not permissible and could be harmful—revert to an approved TCI intervention.
EMPLOYEES
EMPLOYEES on DUTY:
First Name
Last Name
Phoning
Notification Type
Phone Call
Voice Mail
Fax
Email
In-Person
Agency Notified
County Name
Date
Date Format: MM slash DD slash YYYY
Time
:
HH
MM
AM
PM
Number Or Email
VM Left For / Person Spoken With
First
Last
Notification Type
Phone Call
Voice Mail
Fax
Email
In-Person
Agency Notified
County Name
Date
Date Format: MM slash DD slash YYYY
Time
:
HH
MM
AM
PM
Number Or Email
VM Left For / Person Spoken With
First
Last
Notification Type
Phone Call
Voice Mail
Fax
Email
In-Person
Agency Notified
County Name
Date
Date Format: MM slash DD slash YYYY
Time
:
HH
MM
AM
PM
Number Or Email
VM Left For / Person Spoken With
First
Last
INCIDENT CONCERN DESCRIPTION
Staff Debriefing
Yes
No
Reason for No
Staff Recommendations
Staff Signature
*
Date of Staff Signature
*
Date Format: MM slash DD slash YYYY
Name of Supervisor Notified
First
Last
Supervisor Instructions / Comments:
If Police or EMS were called, name of supervisor who authorized the call:
First
Last
Processing Time Start
:
HH
MM
AM
PM
Processing Time End
:
HH
MM
AM
PM
Medical Instructions:
(Use “Na” to Note if Not Applicable)
Oesterlen Nurse:
*
Emergency Room:
EMS:
*
Other Medical Professional:
Notification Summary
County MHRB
Oesterlen Maintenance
ODJFS
County CSB / DJFS
Oesterlen Nurse
ODMH
Emergency Room
Oesterlen Psychiatrist
Parent/Guardian
Fire Department / EMS
Oesterlen Supervisor
Placing Agency (If different from Cty CSB / DJFS)
Law Enforcement
Oesterlen Therapist
Probation Officer
(Check All That Apply)
Copyright © 2018 Oesterlen Services for Youth, Inc. All rights reserved.
