Rcc Incident Reporting Form (Page 2 of 3) in pdf

INCIDENT

Date of Incident: ____________ Time of Occurrence: ____________

Place of occurrence: ________________________

Staff/FP to Child ratio at Time of Incident: ______ Full names of adults responsible for children at the time of the incident: _____________

_______________________________________________________________________________________________________________

WHAT HAPPENED DURING THE INCIDENT:

Include: A) Precipitating Factors: B) What occurred and the timeline; C) Staff/Foster Parent Involvement;

D) Child Injury. If an ESI was part of this incident then add this information to the ESI list on page three. If this was an ESI with injury beyond first aid or a child

has alleged maltreatment during the ESI then a full report is required. (Use page three for additional space if needed.)

A) Precipitating Factors

(Describe the events that preceded this incident that may have contributed to the incident)

B) What Occurred and Timeline

(Describe what happened during the actual incident and the sequence of events)

C) Staff/Foster Parent Involvement

(Describe what actions staff/foster parent took during this event including any notifications made

D) Child injury? Yes ___ No ___

(If yes, include how the injury occurred, who may have caused the injury, the date medical attention was given and by

Was the injury from an ESI and requiring more than first aid: Yes ___ No ___

whom, the diagnosis and the extent of the medical care.

SAFETY PLAN: STEPS TAKEN BY FACILITY TO PREVENT FUTURE INCIDENTS:

Immediate and long term safety plans that ensure the safety

of all children in your care. If there is an alleged perpetrator then include a plan regarding that person’s interactions with children in care. Additionally, a

detailed investigative report which includes steps taken by the facility/agency to prevent similar incidents from occurring is to be completed within five working

days. The investigative report will be kept with the incident report unless requested by ORCC. Use page three for additional space if needed.

NAME OF PERSON(S) ALLEGED TO BE RESPONSIBLE FOR INJURY/ MALTREATMENT:

(List all involved)

Full Name: ______________________________ Staff/Foster Parent ___ Child ___ Other ___

Does this person still have access to children in care and/or are there still foster children in this foster home? Yes ___ No ___

Was this plan approved by the custody holder? Yes ___ No ___ If yes, add the approved plan to the Safety Plan section.

Revised 5/1/2012