Foster Home Incident Report Form

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LoneStar Solutions Incident Report Form (please print or type)
Incident#:______________
(Office use ONLY)
Name of Foster Home:
Date of Incident:
Time of Incident:
Address of incident:
Phone Number of Foster Home:
Involved in incident: (last name):
(first name)
Gender: M / F
SITE OF INCIDENT: (Please check box in front of location)
Foster Home
School
Community
Office
Other Agency
Other
IDENTIFY ALL INVOLVED & WITNESSES (INCLUDING ADULTS):
Name ( First ,Last)
Age
Gender
Date Admitted
Relationship
Circumstances Surrounding Incident:
Interventions Made (i.e. medical, contacts, other):
Resolution of Incident:
Description of Incident (HIPAA no longer requires use of Initials) Please State Facts and Events Observed:
Nature of Incident (Please check all that apply, maximum of three per incident) See Definitions
____ Falls
____ Security/ Safety
_____ Breach of Confidentiality
____ Animal Cruelty
____ AWOL/Elopement/ Runaway
_____ Stealing/ Theft
____ Critical Sexual Incident
____ Verbal Abuse
_____ Self Harm
____ Perpetrator of
___ to Peer
____ Verbal Threat/ Gesture
____ Victim of
___ to Adult
____ Physical Action
____ Sexual Acting Out
____ Aggression to Others
____ Medication Variance
_____ Property Damage
___ Peer
___ Adult
____ Medication Incident
_____ Vandalism
____ Resulting in Injury to Another
____ Critical Event ( see description)
____ Time Out ____ # of Minutes
_____ Fire Setting/ Fire Play
Medical:
____ Acute Medical Condition
Restraint:
____ Contraband
____Chronic Medical Condition
_____ Therapeutic Hold/ Physical Restraint
____ Alcohol
____ Weapon
____ New Medical Condition
______Emergency Medication Adjustment
____ Drugs
____ Other
____ Existing Medical Condition
SCM/SM form must be completed of over
1minute in duration
_____ Excessive Defiance beyond age
Hallucinations
appropriate behavior
____ Auditory
____ Visual
____ Other
Is this a result of faulty assistive device? ___ Y __ N
Explain:
If Yes , Please list Device:____________________________________________________
Signature of Person Preparing Report
Title/Relationship
Date
============================ DO NOT WRITE BELOW THIS LINE=====================================
Date Received
*BHS Only- Date Called In:
Time of Day:
Date Form Received:
Time of Day
Copies: * Caseworker
*RCCL
Revised: 3/5/08

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