* = Required Information
Date of Incident
Time of Incident
Exact Location of Incident
Name of primary resident involved (leave out names of other residents)
Name of the site/house where the primary resident resides (ie. 778 Blair, 2446 15th, 2527 14th, 3223 14th,
778 Blair Ave.
2446 15th Ave., S
2527 14th Ave., S
3223 14th Ave., S
Name(s) and title(s) of staff present and/or Involved
Name and Title of Staff Person completing Incident Report.
Type of Incident (Check all that apply.)
Inapproriate Sexual Behavior
Individual(s) verbally notified of incident within 1 hour of the incident (includes voicemail)
Director of Program Services
Did the incident involve a Manual Hold of the Client? If "YES" STOP here, and complete a EUCP (Emergency Use of Controlled Procedure) Report.
Witness(es) to incident - Please do not include other client names, instead use: Person #1, Person #2, etc.
If property was destroyed/ damaged, please describe
If Medical Attention was required, please describe:
If the person is prescribed a PRN psych med, was it offered?
No PRN prescribed
Not applicable for this incident
PRN offered - Refused by client
PRN offered - Accepted by client (A PRN Actual Use Form Is REQUIRED)
Please describe what led up to the incident and/or what happened just prior to the incident occurring.
Please describe, with attention to detail, what happened.
Please describe what efforts staff made in an attempt to avoid or minimize the severity of the incident.
Please describe the staff response to the incident and/or how the incident was resolved.
Please describe any follow up needed to fully resolve or prevent recurrence of the incident.
Date Report Completed
The following individuals were provided the preceding Incident Report via e-mail (or US mail if no email)
If pattern noted, please describe the plan to reduce likelihood of recurrence.