Instructions: Notify Licensing Agency, Placement Agency and Responsible Persons, if any, by next working day.

    Type of Incident

    Unauthorized AbsenceAgressive Act/SelfAgressive Act/AnotherAgressive Act/StaffAgressive Act/Family, VisitorsAlleged Violation of Rights Sexual Abuse Physical Abuse Psychological Abuse Financial Abuse Neglect Rape Pregnancy Suicide Attempt Other Injury-AccidentInjury-Another ClientInjury-Unknown OriginInjury-Behavior EpisodeEpidemic OutbreakHospitalization Medical EmergencyOther Sexual IncidentTheftFireProperty DamageOther (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?


    Follow up treatment, if necessary

    Action taken or planned (by whom and anticipated results)

    Agencies/Individuals Notified (Specify Name and Telephone Number)