Foster Care Manual: Incident or Unusual Incident Report
This is a very serious form. Hopefully you won’t need to use this form often. You will use it to report any incident or unusual incident. For example you have a 3 year old who needs stitches from falling off a bike or a childwas cut when he put his hand through a window.
On this form you state what happened, when it happened, where it happened, who was there, what you did to remedy the situation.After any incident ,discuss possible ways of preventing a similiar incident from happening again. Ask yourselfwhat changesyou couldmake to minimize or eliminate future recurrences.
This form is for informational purposes only. Get anofficial copy from your Case Worker.
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Date of Report:Time:
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Name of Client: Provider Name:
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Address:
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City: State: Zip Code:
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Phone:
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BSU number: County where facility is located:
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Date of Birth: Sex: Date of Admission:
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Level of Mental Retardation: Date of Incident:Time:
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Location of Incident: (bathroom, Hall, etc.)
Facility / Agency License Number:
Describe in detail exactly what happened and any circumstances which may have precipitated the Incident / Unusual Incident:
(Attach additional sheets if necessary)
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Physician’s name and statement (if applicable) - Include treatment and follow-up action:
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Action taken:
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Other pertinent Information (seizures, visual imparements, safety conditions, etc.):
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Relative or guardian notified: Relationship: Address: Phone:
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Typed/printed name and signature of person reporting:Title:Phone:
Date mailed to:
_______ Regional office of Mental Retardation_______ Office of Children, Youth & Families
_______ County Mental Retardation office_________ Department of Health
_______ Funding agency (specify) ______________________
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