| Date incident was reported to HONH: |
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| Time incident was reported to HONH (please indicate AM or
PM): |
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| Name of person reporting this incident: |
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| Reporter's Email Address: |
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| Reporter's contact number: |
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| Name of primary child involved in this incident: |
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| Child's birthdate |
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| Child's age: |
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| Name of Foster Parent(s) |
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| County agency having custody of child: |
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| County caseworker's name: |
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| HONH Clinician: |
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| Date the incident occurred: |
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| Time the incident occurred (please indicate AM or PM: |
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| Exact time of incident is: |
Known
Unknown
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| Please indicate the incident location type: |
Foster Home
Adoptive Home
School
Community Location
Other
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| Incident location name: |
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| Incident location address: |
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| Incident location telephone number: |
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| This incident is NOT critical (as it does not deal with health, safety or
injury) but it is important enough to share with HONH: |
No
Yes
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| CRITICAL INCIDENT TYPE - check all that apply for this
incident: |
Aggression:Physical Assault
Aggression:Sexual Assault
AWOL**
AWOL return
Criminal /Delinquent Activity
Death of a Client**
Explicit Threat: Harm to Self
Explicit Threat: Harm to Others
Fire Setting
Injury to Client
Injury to Other Caused by Client
Loss, Damage, or Theft
Medical Treatment: First Aid**
Medical Treatment: Emergency Room**
Medical Treatment: Admitted to Hospital**
Medication Concern: Missed Meds
Medication Concern: Refusal to Take
Medication Concern: Change in Medication
Placement Disruption due to Fire, Disaster, etc.**
Police/Sheriff involvement**
Racial Incident Involving Client
Restraint Used on Client**
School discipline of Client: School expulsion
School discipline of Client: School suspension
Self-Injury Inflicted by Client: Self-Injury
Self-Injury Inflicted by Client: Self-Mutilation
Self-Injury Inflicted by Client: Suicide Attempt
Substance abuse/possession
Suspected Abuse or Neglect
Vehicle Accident or Violation
Victim of a crime
Weapon possession/use
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| List all the persons and their contact number who provided professional
medical treatment (if applicable: |
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| List all additional people and their contact number who were involved in
the incident (if applicable: |
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| Who actually observed the incident? |
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| Who told you about the incident? |
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| What happened? (Please be very specific as to whom, what, where, when and
why): |
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| What do you think lead up to or caused the incident? |
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| What was done immediately following the incident? (Please be specific; if
injury, describe how treated): |
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| What needs to be done to keep client/everyone safe at this point? (Safety
Plan): |
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| If a "bear hug" restraint took place,was the client under 80
pounds? |
Yes
No
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| If a "bear hug" restraint took place,was verbal de-escalation attempted
prior to using the physical restraint? |
Yes
No
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| If a "bear hug" restraint took place, how many minutes was the child held
in the Bear Hug? |
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| If a "bear hug" restraint took place, did you sit with the client after
the restraint and have a discussion about the incident? |
Yes
No
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| Who have you notified about this incident? |
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| The following entities have been notified: |
County Hotline
County Caseworker
HONH Clinical Supervisor
HONH Executive Director
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| FOR HONH USE ONLY.................... County
CW____________________________ County Intake/Hotline________________
Other________________________________ |
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