FOSTER REPORT INCIDENT REPORT FORM
Incident Details:
Date of Incident:
Start Time of Incident:
End Time of Incident:
Client(s) Involved:
Age(s) of the client:
Developmental Age(s) of the Client:
Foster/Adoptive Home:
Staff Involved/Role:
Witnesses:
I.
Type of Incident:
Abuse or Neglect:
Allegation against Parent/Guardian/Other Adult
Allegation against Staff/Foster Parent
Refusal to Accept Parental Responsibility
Aggression Behaviors:
Physical Aggression
Significant Disruptive Behavior
Verbal Aggression
Criminal Activity:
Property Destruction
Stealing
Medical:
Communicable Disease
Hospitalization – Medical
Medical Continued:
Hospitalization – Psychiatric
Medical Incident
Medication Error
Medication Issues
Minor Client Injury
Substantial Client Injury
Sexual Behaviors Continued:
Inappropriate Sexual Comment/Gestures
Inappropriate Touch
Indecent Exposure / Nudity
Non-consensual Sexual Behavior
Substance Usage:
Other Substance Use (Describe):
Runaway Behaviors:
Absent Without permission
Runaway
School Report:
Refusal to Attend School
Sexual Behaviors:
Consensual Sex
II.
Nature, Circumstances & Resolution of Incident:
III.
Interventions Made During and After the Incident:
Suicidal/Self Harm:
Body Art
Self Harm
Suicide Attempt
Suicide Threat
Describe what action was taken as a result of this incident (i.e. disciplinary action, individuals notified, medical
interventions, etc).
Foster Parent Incident Report Form
Revised 7/13/2017
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IV.
Follow-up Action:
A. Authorities Notified (i.e., CPS, Police, 911)?
Authority Notified
B. Parents/Guardian Notified?
Yes (complete information below)
Date
Approximate Time
Yes (complete information below)
Parent/Legal Guardian
No
Report Number
No
Date
Approximate Time
Date
Approximate Time
C. Health Care Provider Notified (for medication issues/errors)?
Yes (complete information below)
No
Health Care Professional
V. Containment Report (Complete the following if a containment occurred):
Start Time of Containment:
End Time of Containment:
Client(s) Contained:
Staff involved in containment:
Staff monitoring breathing signs and signs of distress:
Witness:
Behavior constituting Imminent Risk: Harm to Self_______ Harm to Others______
Location of Containment:
1. What constituted an emergency situation prior to the containment?
2.
What specific behaviors were demonstrated prior to the containment?
STEPS TAKEN TO PREVENT CONTAINMENT
1. List at least five de-escalation strategies, less restrictive & intrusive interventions used prior to
containment
2. What were the youth’s reactions to the preventative strategies used?
Foster Parent Incident Report Form
Revised 7/13/2017
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SPECIFIC CONTAINMENT USED
List the type of containment(s) used in chronological order
(1, 2, 3, 4)
Escort
Standing Hug Containment
Standing Elbow to Hip Containment
Follow to Ground
DESCRIPTION OF DE-ESCALATION STRATEGIES DURING CONTAINMENT
1. What de-escalation strategies were used during the containment?
2.
What was said to the client about safe behaviors necessary for release from containment?
CLIENT’S REACTION TO CONTAINMENT DEBRIEFING
1. Date & Time of Discussion:
2. What did the client say about their dangerous behavior?
3. What did the client say about the circumstances leading to the containment?
4. What did the client say about the de-escalation strategies used by staff?
5. What did the client say about the specific containments used by staff?
6. What was the general reaction of the client after the containment?
7. What suggestions did the client make on how to be released from the containment?
Foster Parent Incident Report Form
Revised 7/13/2017
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If applicable print on both sides
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DESCRIPTION OF RETURNING THE CLIENT TO ACTIVITIES
How was the client returned to normal activities following the release from containment?
Did the containment result in any injuries?
Yes
No
Was the injury a hotline reportable injury (ex. resulted in broken bone, concussion, stitches, etc.)?
Yes
No
N/A
If yes, action taken:
Is this the third (3) containment for the client in seven (7) days?
Was client observed for 15 minutes following containment?
Is there a current behavior treatment plan for this client?
Yes
Yes
Yes
No
No
No
Supervisor Contacted:
Time Contacted:
Parent/Legal Guardian Debriefing Meeting Date & Time:
Were the following items discussed during the debriefing meeting?
Yes
No
Evaluation of the well-being of the client and identification of the need for
counseling or other services related to the incident
Yes
No
Identification of antecedent behavior, behavior management interventions
utilized by staff, and client’s responses to interventions including the
containment
Yes
No
Modification of the behavior management plan and/or plan of service
as appropriate
Yes
No
Analysis of how the incident was handled and identification of needed
changes to procedures and/or staff training
Foster Parent Incident Report Form
Revised 7/13/2017
P:\Agency Forms\Residential\Foster Care\Foster Child Forms
If applicable print on both sides
Page 4 of 4