Was client injured as result of abuse? Yes or No Was Treatment Required? Yes or No Treatment Location: (choose all that apply) ER Crisis Assessment □ □ Admitted to hospital Residence □ □ Physician’s Office Provider’s Office □ □ Sexual Abuse/Exploitation Sexual Abuse/Exploitation Yes or No Abuse by Provider Yes or No Staff/provider Name Abuse by another client Yes or No Type of Sexual Abuse: (Choose all that apply) Visual Aggressor (Exposure) □ Was Treatment Required? Yes or No Pornography □ Inappropriate Conversations □ Treatment Location Sexual Contact □ (choose all the apply) Crisis Helpline □ ER Assault line □ Other: _______________________ □Sexual Physician’s Office Other ____________________ □ Forensic Assault Exam Performed? Yes or No Neglect Type of Neglect: (choose all that apply) Deprivation of essential needs □ Neglect Yes or No Provider neglect (abandonment, inattentive to child, supervisory neglect, □ environment neglect, etc.) Providers under influence □ Abuse by Provider Yes or No Staff/Provider Name Verbal/Emotional Abuse by Provider Yes or No Staff/provider Name Abuse by another client Yes or No Dangerous Situation Summary of Event: Summary of dangerous situation. Why was this a risk to client? Was client a risk to others? Response: Describe provider response to situation Dangerous Situation Type: (choose all that apply) Arson Hostage/Kidnapping □ □ Building rendered inhabitable Injury to staff by client □ □ Client as aggressor/perpetrator Loss of Home (disaster) □ □ Explosion Significant property damage □ □ Fire □
Was client injured as result of abuse? Yes or No Was Treatment Required? Yes or No Treatment Location: (choose all that apply) □ ER □ Admitted to hospital □ Physician’s Office □ Crisis Assessment □ Residence □ Provider’s Office Sexual Abuse/Exploitation Sexual Abuse/Exploitation Yes or No Abuse by Provider Yes or No Staff/provider Name Abuse by another client Yes or No Type of Sexual Abuse: (Choose all that apply) □ Visual Aggressor (Exposure) □ Pornography □ Inappropriate Conversations □ Sexual Contact Other: _______________________ Was Treatment Required? Yes or No Treatment Location (choose all the apply) □ ER □ Physician’s Office □ Crisis Helpline □Sexual Assault line Other ____________________ Forensic Assault Exam Performed? Yes or No Neglect Neglect Yes or No Type of Neglect: (choose all that apply) □ Deprivation of essential needs □ Provider neglect (abandonment, inattentive to child, supervisory neglect, environment neglect, etc.) □ Providers under influence Abuse by Provider Yes or No Staff/Provider Name Verbal/Emotional Abuse by Provider Yes or No Staff/provider Name Abuse by another client Yes or No Dangerous Situation Summary of Event: Summary of dangerous situation. Why was this a risk to client? Was client a risk to others? Response: Describe provider response to situation Dangerous Situation Type: (choose all that apply) □ Arson □ Building rendered inhabitable □ Client as aggressor/perpetrator □ Explosion □ Fire □ Hostage/Kidnapping □ Injury to staff by client □ Loss of Home (disaster) □ Significant property damage