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Submit a Special Incident Report


*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.

    Certified Parent Name:



    Incident Date Unknown


    Incident Time Unknown

    Incident Types:

    Behavioral/Mental Health Incident

    Injury, Illness or Accident

    Death

    Unauthorized Absence

    Child Abuse

    Agency Emergency/Disaster

    Other

    Comments: