Client Incident Report
Client(s) M.R. #: _____________________ Date: ______________
Staff on Duty: ______________________
Was staff involved in the incident? ________
Did staff witness incident: ______________
Incident Type: (check one)
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Abuse/Neglect/Exploitation |
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Automobile Accident |
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Sexual Battery |
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Use of Alcohol |
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Baker Act |
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Suicide Attempt |
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Aggressive/Abusive Behavior |
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Client Death |
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Theft |
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Use of Drugs |
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Elopement |
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Verbal threat of violence |
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Altercation |
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Law Violation |
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Other (explain on page 2) |
Action Taken:
Supervisor Contacted: _________________ Name of Supervisor: __________________
Called 911: _________ Follow up Necessary: ________________________________
Describe Incident:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisory Intervention Strategy:
Describe Intervention:
______________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor Signature: _________________________ Date: ________________________
Printed Name: ___________________________________
Executive Director Comments:
Comments:
________________________________________________________________________________________________________________________________________________________________________________
Executive/Clinical Director Signature: _______________________
Describe Incident:
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