Staff Members / Foster Parent (Use additional paper if needed) Full Name Position (If foster parent, provide number) Behavior Management Certified (Y/N) (For RCC staff only) Others involved in the incident: School Staff/Probation Officers/Neighbors, etc. (Use additional paper if needed) Full Legal Name Relationship to Minor Youth Contact Phone # (yes/no) Incident Type Choose as many as to the situation. Be sure that each issue identified is addressed in the narrative. Arrest/Incarceration of or Foster Parent While On Injury To Youth Subject Of The Incident Duty Possible Violation Of Youth’s Rights Assault Of Youth Subject Of The Incident Property Damage Assault On Foster Restraint Assault On Other Youth (provide specifics in identified section below) Automobile/Vehicular Accident Sexual Assault - Perpetrator Death Of Child Sexual Assault - Victim Death Of Staff /Foster Parent While On Duty Suspected Domestic or Intimate Partner Violence (provide specifics in identified section below) Injury To Other Youth - Perpetrator Injury To Foster Parent/Staff - Victim Behavioral Issues School Suspension (> 3days) Suicidal Attempt Arrest/Incarceration of Youth Sexual Misconduct Suicidal Ideation Awol Medical/Psychiatric Events Bullying - Perpetrator Mental Health/Substance Use Emergency Hospitalization Bullying - Victim Alcohol Use/Posession Medical Fire Setting Drug Use/Possession Psychiatric Gang Involvement Emergency Petition Emergency Medical Treatment Police Involvement Homicidal Attempt Emergency Psychiatric Evaluation Possession Of Contraband Homicidal Ideation Medical Event (Significant but School Expulsion Ingestion Of Harmful Substance School Refusal Injury To Self Medication Error(s)
Staff Members / Foster Parent (Use additional paper if needed) Full Name Position (If foster parent, provide number) Behavior Management Certified (Y/N) (For RCC staff only) Others involved in the incident: School Staff/Probation Officers/Neighbors, etc. (Use additional paper if needed) Full Legal Name Relationship to Minor Youth (yes/no) Contact Phone # Incident Type Choose as many as to the situation. Be sure that each issue identified is addressed in the narrative. Arrest/Incarceration of or Foster Parent While On Duty Assault Of Youth Subject Of The Incident Assault On Foster Assault On Other Youth Automobile/Vehicular Accident Death Of Child Death Of Staff /Foster Parent While On Duty Domestic or Intimate Partner Violence Injury To Other Youth Injury To Foster Parent/Staff Injury To Youth Subject Of The Incident Possible Violation Of Youth’s Rights Property Damage Restraint (provide specifics in identified section below) Sexual Assault - Perpetrator Sexual Assault - Victim Suspected (provide specifics in identified section below) - Perpetrator - Victim Behavioral Issues Arrest/Incarceration of Youth Awol Bullying - Perpetrator Bullying - Victim Fire Setting Gang Involvement Police Involvement Possession Of Contraband School Expulsion School Refusal School Suspension (> 3days) Sexual Misconduct Mental Health/Substance Use Alcohol Use/Posession Drug Use/Possession Emergency Petition Homicidal Attempt Homicidal Ideation Ingestion Of Harmful Substance Injury To Self Suicidal Attempt Suicidal Ideation Medical/Psychiatric Events Emergency Hospitalization Medical Psychiatric Emergency Medical Treatment Emergency Psychiatric Evaluation Medical Event (Significant but Medication Error(s)