UNUSUAL INCIDENT/INJURY REPORT Instructions: Notify Licensing Agency, Placement Agency and Responsible Persons, if any, by next working day. Type of Incident Unauthorized Absence Agressive Act/Self Agressive Act/Another Agressive Act/Staff Agressive Act/Family, Visitors Alleged Violation of Rights Sexual Abuse Physical Abuse Psychological Abuse Financial Abuse Neglect Rape Pregnancy Suicide Attempt Other Injury-Accident Injury-Another Client Injury-Unknown Origin Injury-Behavior Episode Epidemic Outbreak Hospitalization Medical Emergency Other Sexual Incident Theft Fire Property Damage Other (explain) Describe Event or Incident (Include Date, Time, Location, Perpetrator, Nature of Incident, Any antecedents leading up to incident and how clients were affected, including any injures) Person(s) who observed the incident/injury Explain what immediate action was taken (include persons contacted) Medical Treatment Necessary? Yes No Follow up treatment, if necessary Action taken or planned (by whom and anticipated results) Agencies/Individuals Notified (Specify Name and Telephone Number)
