Misconduct Incident Report (Page 8 of 8) in pdf

F-62447 (Rev. 04/10)

Page 8 of 8

FOLLOW UP QUESTIONS TO BE ASKED BY THE ENTITY

It is suggested that entities ask the following questions to obtain additional, detailed information about reported incidents. Please record all

responses in the space provided. Attach additional pages, information, documentation, diagrams, photographs, or other evidence as

appropriate.

Check if additional pages are included.

Check if items or documents are attached.

Check if a photocopy of an item or document is attached.

Check if an item or document is being retained by the entity; describe where and how it is being stored pending the outcome of this

investigation.

▪

How do you know about the above incident? Did you do it? Did it happen to you? Did you see it? Did another person tell you of it? If

so, who?

▪

Time and date of the incident. When did it happen? When did you first learn about it?

▪

Location. (Where did the incident occur? Where were you when it happened? If others were present, who and where were the others?

Where were you when you learned about it or saw it? Describe the location. Attach a diagram.)

▪

Was anyone else present when it happened, you learned about it, or when you saw it? If so, who? Where was each person?

▪

Did you tell anyone about the incident? If so, what did you tell them, who did you tell and when did you tell them? What did the person

say, if anything?

▪

Was anyone harmed in any way (physically or sexually, emotionally or mentally, or financially) or could someone have been harmed?

If so, describe the harm or potential harm.

▪

Were others harmed in any way? If so, identify the person who was harmed and describe the harm.

▪

Describe the affected person’s actions or reactions during the incident including statements made, changes in demeanor, or other

indications of pain, fear, sadness, anger, humiliation, etc.

▪

Describe the actions or reactions of others who observed or were involved in the incident.

▪

For Affected Persons: Did you tell anyone about what happened to you? If so, who did you tell and when and where did you tell

them?

▪

For Other Witnesses: Is or was the affected person able to report or talk about the incident?

▪

If so, did the affected person say anything to you? If so, what? Describe the way that the affected person acted when telling you about

the incident.

▪

To your knowledge, did the affected person tell anyone else? If so, who and when?

▪

Are there others who know or may know about the incident? If so, who are they and why do you think they have information about the

incident?

▪

Do you have or are you aware of any evidence, documentation or information that may be relevant to the incident? (Examples:

photos, diagrams, maps, receipts, video tapes, audio tapes, medical records, care plans, financial transaction records, etc.) If so, what

is it and where is it?

Additional Information

Name - Person Interviewed

Name - Person Conducting the Interview

Interview Date (mm/dd/ccyy)

Misconduct Incident Report Page 8

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