Incident Intake Information Form - Georgia Department Of Human Services
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3DEPARTMENT OF HUMAN SERVICES
OFFICE OF RESIDENTIAL CHILD CARE
INCIDENT INTAKE INFORMATION FORM
This form is to be filled our completely and submitted via email to RCCReports@dhr.state.ga.us. Hand written and phone reports are not accepted.
Facility ID #: CCI00_____ CPA00_____ CPFC00_____ OCCP00_____ OTP00_____ MH00_____ CTCC00_____ Date:
Facility’s Licensed Name: _________________________________________________________ CPA Satellite Office:
_______
Facility’s Full Site Address: ____________________________________________________________________County: ___________
Phone: ______________ E-mail: ________________________________ Was the Director notified of incident? Yes ___ No ___
REPORTER
Full Name (First & Last): ___________________________________________________________ Position/Title: _________________
Work Phone: ______________ Cell Phone: ______________ E-mail: ___________________________________________________
REASON FOR REPORT
(Check all that apply in the boxes below)
___Serious
___Suicidal
___ Emergency Safety Intervention
___Temporary Closure of a Living
___Physical Abuse Allegation
Accident/Injury
Actions
(ESI) (List on page three)
Unit
___Sexual Abuse and/or
___ Law
___ ESI with Injury Beyond First
___ Unplanned Hospital or Urgent
___ Neglect
Exploitation Allegation
Enforcement
Aid (Full report required as well)
Care
__CPS Involvement (Describe):
__ Other Serious Occurrence (Describe):
CPS NOTIFICATION (REQUIRED FOR ALL PHYSICAL/ SEXUAL ABUSE AND NEGLECT ALLEGATIONS)
Was a CPS referral made to the county of occurrence or the CPS Hotline? Yes ___ No ___ Date of Report:
CHILD/ RESIDENT
(List each child involved in this incident. Use page three for space for additional children’s information if needed)
#1: Child’s Full Name________________________________________________________________________________
Date of Admission __________ Date of Birth ____________
Male ___ Female ___
DFCS County of Custody ____________ Case Manager Name ________________________ Phone ______________
DJJ County ____________ Probation Officer Name _________________________ Phone ______________
Parent/ Guardian notified: Yes ___ No ___
Date Notified:
Time Notified: _______
#2: Child’s Full Name________________________________________________________________________________
Date of Admission __________ Date of Birth ____________
Male ___ Female ___
DFCS County of Custody ____________ Case Manager Name ________________________ Phone ______________
DJJ County ____________ Probation Officer Name _________________________ Phone ______________
Parent/ Guardian notified: Yes ___ No ___
Date Notified:
Time Notified: _______
FOSTER PARENT/ADOPTIVE PARENT WHERE CHILD WAS PLACED DURING THE INCIDENT
(Foster Care/Adoption Only)
Full Name of Foster Mother: _________________________ Full Name of Foster Father: __________________________
Full Address: ____________________________________________________________ County: ___________________
Home Phone: ______________ Cell Phone: ______________ Best Time to Reach: __________
WITNESS
Full Name:
__________________________________ Staff ___ Foster Parent ___ Child___ Other: ___
Work Phone: ______________ Cell Phone: ______________ Best Time to Reach: __________
Revised 5/1/2012
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