Foster Care and Adoption
*By submitting a Special Incident Report electronically through this form, you acknowledge and understand that you are solely responsible for ensuring the report is received. If you do not receive a response from a social worker or staff member within 1 hour of submitting the report, you must follow up immediately by phone, text, or email following the chain of command (social worker first, supervisor second, and program director third) until you receive a response.
Last Name First Name
Incident Date Incident Date Unknown
Incident Time Incident Time Unknown
Location of Incident ---Afterschool programChildcare providerChurchCourtCurrent placementFriend's homeHome of parentHome of relativesIn transitNeighborsOtherPrior foster placementSchoolUnknown
Behavioral/Mental Health Incident Assaultive Behavior(Caregiver)Assaultive Behavior(Peer)Assaultive behavior (Other)Inappropriate Sexual BehaviorMedical RelatedPhysical RestraintPolice InvolvementProperty Damage SeclusionSelf Injurious BehaviorStaff RelatedSubstance AbuseSuicidal IdeationSuicide AttemptTheft
Injury, Illness or Accident AccidentIllnessInjuryHospitalization(Medical)Hospitalization(Psychiatric)
Death Death
Unauthorized Absence AbductionRunaway
Child Abuse NeglectPhysicalSexualVerbal/Emotional
Agency Emergency/Disaster Earthquake DamageEpidemicExplosionFireFlood
Other Other
Describe the Incident
Describe the Injuries Sustained and Care Given/Medical Intervention
Conclusions/Action Taken
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X
Yes
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