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Incident Report
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1. Type of Service
Adult – Mental Health
Adult – Substance Abuse
Other
Other
2. Location of Incident:
Residential
type (e.g. LTSR, RTF)
type (e.g. LTSR, RTF)
Location of Incident 2:
Outpatient
Inpatient
Partial Hospital Program
Other Day Program
type (e.g. clubhouse)
type (e.g. clubhouse)
Other
type (e.g. Office, private residence)
3. Client Name
*
First
Last
4. Date of Birth:
*
5. Client Address
*
6. Date of Incident
*
Time:
*
ampm
AM
PM
7. Client Phone Number
7a. Name of Reporting Agency:
8. Name, Title, and Phone # (of person filing report)
9. Agency/program where incident occurred (if different from box 7a )
10. Location/address where incident occurred (if different from box 9)
11. Other witnesses to the incident:
12. Indicate type of incident (check all that apply)
Death of a Client
Homicide committed by Client who is receiving services or has been discharged within 30 days
Suicide attempt (with or without medical attention)
Act of violence requiring medical intervention (includes intervention provided by staff nurse or physician), by or to a Client
Alleged or suspected abuse (physical, sexual, financial or verbal) of or by a Client
Adverse reaction to medication and/or medication error administered by a provider
Neglect resulting in injury or hospital treatment
Any sexual contact involving a minor (includes peer to peer contact)
Restraints (physical, mechanical, and/or chemical)
Seclusion
Police involvement or arrest (excludes involuntary commitments)
Fire, flood, or serious property damage at a site where behavioral health services are delivered or a facility where Clients reside.
Any physical ailment or injury that requires medical attention at a hospital on an emergency, outpatient or inpatient basis (including visits to urgent care).
Contraband found on facility premises (illicit substances or synthetic cannabinoids)
All non-routine discharges from inpatient, residential rehab (D&A), children’s residential, detoxification, or Medication Assisted Treatment – i.e., administrative/involuntary discharges or leaving a facility against medical or facility advice (AMA, AFA, AWOL)
nfectious disease outbreak at a provider site
Missing person: child/adolescent who has not returned home or facility within 4 hours or an at-risk adult who has not returned home within 24 hours (includes filing a police report)
Staff Issue (Office, Clinical, Administrative)
Alleged or suspected abuse (physical, sexual, financial or verbal) in the household of a client
Other
Other
13. Summarize the incident. Include precipitating factors, current status, and a description of any injuries, medical condition, (if applicable):
14. Describe any corrective actions taken at the time of the incident:
Pending investigation?
Yes
No
All pending investigations (internal) should be completed & written findings reported on next sheet.
15. Which of the following persons were notified by telephone?
Psychiatrist
Name of Person, Phone #, Date, Time
notified
Family/Significant Other
Name of Person, Phone #, Date, Time
notified 2
Case Mgr. or Therapist
Name of Person, Phone #, Date, Time
notified 3
Supervisor
Name of Person, Phone #, Date, Time
notified 4
Executive Director or Designee
Name of Person, Phone #, Date, Time
notified 5
Police
Name of Person, Phone #, Date, Time
notified 6
Fire Dept.
Name of Person, Phone #, Date, Time
notified 7
DCFS/ChildLine
Name of Person, Phone #, Date, Time
notified 8
ODMHS
Name of Person, Phone #, Date, Time
notified 9
Other agency
Name of Person, Phone #, Date, Time
17. Summarize any action taken by the supervisor or reviewing Family Unity CC Authority:
18. If an investigation was conducted, please describe the investigation and the outcome of the investigation and final action taken and the dates taken:
Reviewed by Supervisor:
Date
Reviewed by Department Head:
Date
Reviewed by Executive Director:
Date
Email
*
of investigation 5.
20. Other Departments or Individuals notified and will conduct separate departmental review based on that departmental policy:
Clients Rights Officer
Human Resource Departmental Review
Executive Director or Chief Clinical and Operating Officer
Submit
