Incident Report Child Incident Report InformationYour Work Email A#(Required) Incident Type(Required)--None--BehavioralMinor Medical IncidentEmergency Medical IncidentAggression towards OthersDestruction of PropertySelf HarmInappropriate Sexual BehaviorSexual AbuseSexual HarrassmentOtherDirect Supervisor Email This is the staff manager you report to.Date/Time Reported to Personnel(Required) MM slash DD slash YYYY Time Reported to Personnel(Required) Hours : Minutes AM PM AM/PM Supervisor Verbal Notification(Required)YesNoReport InformationLocation of Incident(Required) Date of Incident(Required) MM slash DD slash YYYY Time of Incident(Required) Hours : Minutes AM PM AM/PM Other ORR Children Involved First Last Personnel Witnesses First Last Incident DescriptionIncident Description(Required) Use 3rd person narrativeTranslation & Clarifying Info Other InformationAdditional Follow-up--None--One-on-One Session with ClinicianOne-on-One Session with Case ManagerFamily SessionMeeting with the Treatment TeamMedical CoordinatorPSAOtherSelect additional follow up neededStaff's Immediate ResponseContact & EngagementProtecting from Futhur Harm (rest time)Active ListeningCompassionEmpathyHelped with RegulationSensory Bin or Photobook PlayOtherSelect the staffs immediate response to the child (select all that apply).Preventative Actions Before/After 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?Staff's Immediate Response (Other) Enter the staff's immediate response if 'Other' is selected in the Staff's Immediate Response field.SIR OnlyIs this an SIR?NoYesWas this incident filed in the UC Portal as an SIR? Only mark "Yes" if already submitted in UC Portal.SIR Event Number
