Incident Report
This form is only to be completed if the user(s) are not able to view a child/youth in TFACTS or if there is a system failure.
Child’s Name / Incident DateCase ID / Client ID / Referral to CPS / Yes No
Date Referral Made:
Time Referral Made:
Intake Number / Notify Family / Yes No
Date Notification Made:
Time Notification Made:
Runaway/Escape Information / Date Police Notified: / Complaint No: / Police Dept: / Date Listed in NCIC: / NCIC No: / Does child/youth have any history of violence against people? YesNo
Incident Type / Incident Sub-type 1 / Incident Sub-type 2 / Incident Sub-type 3
Abduction / None / None / None
Arrest/Police Involvement with Child or Youth / Child/youth arrestedChild/youth police involvement, no arrest / None / None
Assault / Assault - Youth on YouthAssault - Youth on StaffPhysical Fight between Youth / With InjuryWithout Injury / With Use of WeaponWithout Use of Weapon
Contraband / TobaccoAlcoholIllegal DrugsPrescription DrugsDrug ParaphernaliaWeaponUse of Drug(s)/Intoxicant(s)Other (specified) / None / None
Emergency Medical Treatment / Injury-accidentalInjury-non-accidentalIllness-ongoingIllness-sudden onset / HospitalizationOutside medical clinic eval/trtd & rel child/youthAgency medical staff eval/trtd & rel the child/youContact with PCP prior to ER visitNo Contact with PCP prior to ER visit / None
Emergency Use of Psychotropic Medication(s) / Acute psychotic episodeAcute behavioral outburstSeclusion and restraintOther (detail below) / Oral med (list medication name & dose below)Injection (list medication name & dose below) / None
Major Event at Agency / Youth DisturbanceFireEvacuationPhysical Plant IssuesBomb ThreatOther / Riot with Police InvolvementOther (explain in narrative) / None
Mechanical Restraint / Security and ControlPsychiatric CrisisTransportation / Duration 0-14 minutesDuration 15-30 minutesDuration over 30 minutes / With InjuryWithout Injury
Medication Error / No harmIncreased monitoring, no harmMedical trtmnt/hospt, potential temp or perm. harm / Medication unavailable at placementMedication unavailable during passFailed to administer medication at placementFailed to administer medication during passChild/youth refused med for at least 48 hoursChild/youth hid (cheeked) medicationWrong DoseWrong MedicationWrong TimeExpired MedicationNo Informed ConsentChild admitted wtihout medication / None
Mental Health Crisis / Mobile crisis phoneMobile crisis face to faceER staff - non-mobile crisisIntervention by in-house agency clinician/therapisHospitalization for acute psychiatric reasons / ER eval/trtd & rel the youthHospitalized for medical reasons (hosp name below)Agency med staff eval/trtd & rel the youthOutside med clinic eval/trtd & rel the youthActive Suicide Watch / None
Physical Restraint / Duration 0-14 minutesDuration 15-30 minutesDuration over 30 minutes / With InjuryWithout Injury / None
Runaway/Escape / Ran from Agency PersonnelRan from School/Pass / Child ReturnedChild has Not Returned / None
Seclusion / Duration 0-30 minutesDuration 31-60 minutesDuration over 60 minutes (detail below) / None / None
Sexual Abuse / Youth on YouthStaff on Youth / With InjuryWithout Injury / None
Sexual Harassment / Youth on YouthStaff on Youth / None / None
Property / Destruction/Damage/Stolen/Missing Personal PropertDestruction/Damage/Stolen Missing State PropertyDestruction/Damage/Stolen/Missing Agency PropertyArsonTheft / None / None
Confinement / Protective Custody / less than 120 hrsover 120 hrs / None
Confinement / Emergency / less than 24 hrsover 24 hrs / None
Search / Strip SearchBody Cavity / None / None
Security Breach / Lost or missing tools/keysOther / None / None
Use of Chemical Defense Spray / None / None / None
Note: Highlighted Gray: are to only be used by YDCs/Detention Centers
Staff Involved / Contact Person / Contact Person’s Telephone() -
Reported By / Date and Time Reported / Date and Time of Incident
Incident Details
Case Information and Location Details
Region / Family Service Worker
Team Leader / Placement Type
Agency / Placement
Location
Placement Address / Incident Address
Foster Parent/Group Home Name
Check the “Forms” Webpage for the most current version and disregard all previous versions. This form may not be altered without prior approval.
Distribution of Copies: DCS Central Office, Child/Youth’s Case File RDA 2982
CS-0496 Rev. 4/18 Page 1 of 2