Respite care for children with higher needs

Incident Report Form

Instructions: Complete this form for all incidents within 24 hours. Submit the completed form to your direct supervisor. For emergencies requiring immediate action, notify appropriate parties (911, supervisors, parents/guardians) before completing this form. 

Section1 : General Information

Date of Incident required

Time of Incident:

Location of Incident:

Person Completing Report

Contact Information

Section 2: Individuals Involved

Name:

Age:

Parent / Guardian Contact Information:

Name(s) of Other Individuals Involved and Role / Relation to Youth (e.g., family members, bystanders): 

Section 3: Incident Details / Type of Incident:

Other (please specify):

Detailed Description of Incident:

Include incident leading up to the situation, what happened, actions taken, and any statements made by those involved. Please just include factual information about what occurred.

Signature

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Name:

Date: required

Thanks for submitting!