This form is to be completed when there is an incident which occurs that is inconsistent with the routine operations and service provided, including but not limited to injury to a resident or staff, property destruction, resident elopement or staff errors that cause harm (or potential harm) to a resident. Any incidents, complaint or circumstances that may cause ill will to the agency or its personnel must also be reported using this form. This form must be FULLY COMPLETED and SUBMITTED before the end of the shift in which the incident occurred. The Lead DSP or Program Director must also be notified verbally before the end of the shift. If 2 residents are affected by the same incident, SEPARATE incident Reports must be submitted.
Date and 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. Oliver, Running Park, Sander, etc.)
Bossen 1 Apartments
Bossen 2 Apartments
Christian Park House
Morris Park Apartments
Running Park House
Sander 1 Apartments
Sander 2 Apartments
Sander 3 Apartments
Wrights Lake House
Name(s) and title(s) of staff present
Name and Title of Staff Person
completing Incident Report.
Type of Incident (Check all that apply.)
Inappropriate 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/
If Medical Attention was required,
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.
A reminder that other resident's names must be excluded, in favor of (Person #1, Person #2, etc).
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 and Time Report Completed:
The following individuals were provided the
preceding Incident Report via e-mail
(or US mail if no email):
Date and Time sent
If pattern noted, please describe the
plan to reduce likelihood of recurrence.