FOSTER REPORT INCIDENT REPORT FORM

Incident Details:
Date of Incident: / Start Time of Incident: / End Time of Incident:
Client(s) Involved:
Age(s) of the client:
Developmental Age(s) of the Client:
Foster/Adoptive Home:
Staff Involved/Role:
Witnesses:
I. Type of Incident:
Abuse or Neglect:
Allegation against Parent/Guardian/Other Adult
Allegation against Staff/Foster Parent
Refusal to Accept Parental Responsibility
Aggression Behaviors:
Physical Aggression
Significant Disruptive Behavior
Verbal Aggression
Criminal Activity:
Property Destruction
Stealing
Medical:
Communicable Disease
Hospitalization – Medical / Medical Continued:
Hospitalization – Psychiatric
Medical Incident
Medication Error
Medication Issues
Minor Client Injury
Substantial Client Injury
Runaway Behaviors:
Absent Without permission
Runaway
School Report:
Refusal to Attend School
Sexual Behaviors:
Consensual Sex / Sexual Behaviors Continued:
Inappropriate Sexual Comment/Gestures
Inappropriate Touch
Indecent Exposure / Nudity
Non-consensual Sexual Behavior
Substance Usage:
Other Substance Use (Describe):
Suicidal/Self Harm:
Body Art
Self Harm
Suicide Attempt
Suicide Threat
II. Nature, Circumstances & Resolution of Incident:
III. Interventions Made During and After the Incident:

Describe what action was taken as a result of this incident (i.e. disciplinary action, individuals notified, medical interventions, etc).

IV. Follow-up Action:

A. Authorities Notified (i.e., CPS, Police, 911)? Yes (complete information below) No

Authority Notified / Date / Approximate Time / Report Number

B. Parents/Guardian Notified? Yes (complete information below) No

Parent/Legal Guardian / Date / Approximate Time

C. Health Care Provider Notified (for medication issues/errors)?

Yes (complete information below) No

Health Care Professional / Date / Approximate Time
V. Containment Report (Complete the following if a containment occurred):
Start Time of Containment: / End Time of Containment:
Client(s) Contained:
Staff involved in containment:
Staff monitoring breathing signs and signs of distress:
Witness:
Behavior constituting Imminent Risk: Harm to Self______Harm to Others______
Location of Containment:

1.  What constituted an emergency situation prior to the containment?

2.  What specific behaviors were demonstrated prior to the containment?

STEPS TAKEN TO PREVENT CONTAINMENT

1.  List at least five de-escalation strategies, less restrictive & intrusive interventions used prior to containment

2.  What were the youth’s reactions to the preventative strategies used?

SPECIFIC CONTAINMENT USED

List the type of containment(s) used in chronological order

(1, 2, 3, 4)

Escort

Standing Hug Containment

Standing Elbow to Hip Containment

Follow to Ground

DESCRIPTION OF DE-ESCALATION STRATEGIES DURING CONTAINMENT

1.  What de-escalation strategies were used during the containment?

2.  What was said to the client about safe behaviors necessary for release from containment?

CLIENT’S REACTION TO CONTAINMENT DEBRIEFING

1.  Date & Time of Discussion:

2.  What did the client say about their dangerous behavior?

3.  What did the client say about the circumstances leading to the containment?

4.  What did the client say about the de-escalation strategies used by staff?

5.  What did the client say about the specific containments used by staff?

6.  What was the general reaction of the client after the containment?

7.  What suggestions did the client make on how to be released from the containment?

DESCRIPTION OF RETURNING THE CLIENT TO ACTIVITIES

How was the client returned to normal activities following the release from containment?

Did the containment result in any injuries? Yes No

Was the injury a hotline reportable injury (ex. resulted in broken bone, concussion, stitches, etc.)? Yes No N/A

If yes, action taken:

Is this the third (3) containment for the client in seven (7) days? Yes No

Was client observed for 15 minutes following containment? Yes No

Is there a current behavior treatment plan for this client? Yes No

Supervisor Contacted:

Time Contacted:

Parent/Legal Guardian Debriefing Meeting Date & Time:

Were the following items discussed during the debriefing meeting?

Yes No Evaluation of the well-being of the client and identification of the need for counseling or other services related to the incident

Yes No Identification of antecedent behavior, behavior management interventions utilized by staff, and client’s responses to interventions including the containment

Yes No Modification of the behavior management plan and/or plan of service as appropriate

Yes No Analysis of how the incident was handled and identification of needed changes to procedures and/or staff training

Foster Parent Incident Report Form
Revised 5/6/2015
P:\Agency Forms\Residential\Foster Care\Foster Child Forms / If applicable print on both sides
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