Incident Report

Child Incident Report


This is the staff manager you report to.
MM slash DD slash YYYY
Time Reported to Personnel(Required)

Report Information

MM slash DD slash YYYY
Time of Incident(Required)
Other ORR Children Involved
Personnel Witnesses

Incident Description

Use 3rd person narrative

Other Information

Select additional follow up needed
Select the staffs immediate response to the child (select all that apply).
Enter a description of preventive actions taken before and after the incident. Explain any actions taken prior to the incident to prevent it. For example, was the RBHA, Probation, DCS Specialist, or DDD engaged prior to incident? What actions were taken after the incident to prevent the incident from occurring again?
Enter the staff's immediate response if 'Other' is selected in the Staff's Immediate Response field.

SIR Only

Was this incident filed in the UC Portal as an SIR? Only mark "Yes" if already submitted in UC Portal.