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)