THOMAS ALLEN, INC. , MN (651)450-1802 FAX: (651)450-7923 INCIDENT REPORT (NON-VULNERABLE) CLIENT: DATE: DATE OF INCIDENT: TIME OF INCIDENT: AM PM LOCATION OF INCIDENT: OTHER CLIENT(S) INVOLVED: (Refer to other clients as client #2, #3, etc.) STAFF INVOLVED: (NAME/TITLE) OTHERS INVOLVED: (NAME/RELATIONSHIP) TAI PROGRAM NAME: Incident Type which type): Note: All incidents must be reported immediately to the program supervisor when an incident occurs or after becoming aware of an incident. Incidents are as defined in TAI’s Incident Response and Reporting policy. Serious Injury of a client Sexual Activity between clients involving force or coercion Client medical emergency, unexpected serious illness, Conduct by a client against another client that is so or significant unexpected changes in an illness or severe, pervasive or objectively offensive that it medical condition of a client that requires the program substantially interferes with a person’s opportunities to call 911, physician treatment, or hospitalization to participate in or receive service or support, places Any mental health crisis that requires the program to a person in actual and reasonable fear of harm, call 911, a mental health crisis intervention team or a places the person in actual and reasonable fear of similar mental response team or service when available damage to property of the person or substantially and appropriate disrupts the orderly operation of the program An act or situation involving a client that requires Client unauthorized or unexplained absence program to call 911, law enforcement or the fire department Death of a client Describe Incident, Staff Response and Resolution of incident, including treatment given and client response (use additional sheets if necessary): Signature of Reporter Position/Title Internal Review, comments and corrective actions/written recommendations or service delivery changes
THOMAS ALLEN, INC. , MN (651)450-1802 FAX: (651)450-7923 INCIDENT REPORT (NON-VULNERABLE) CLIENT: DATE: DATE OF INCIDENT: TIME OF INCIDENT: AM PM LOCATION OF INCIDENT: OTHER CLIENT(S) INVOLVED: (Refer to other clients as client #2, #3, etc.) STAFF INVOLVED: (NAME/TITLE) OTHERS INVOLVED: (NAME/RELATIONSHIP) TAI PROGRAM NAME: Incident Type which type): Note: All incidents must be reported immediately to the program supervisor when an incident occurs or after becoming aware of an incident. Incidents are as defined in TAI’s Incident Response and Reporting policy. Serious Injury of a client Sexual Activity between clients involving force or coercion Client medical emergency, unexpected serious illness, or significant unexpected changes in an illness or medical condition of a client that requires the program to call 911, physician treatment, or hospitalization Conduct by a client against another client that is so severe, pervasive or objectively offensive that it substantially interferes with a person’s opportunities to participate in or receive service or support, places a person in actual and reasonable fear of harm, places the person in actual and reasonable fear of damage to property of the person or substantially disrupts the orderly operation of the program Any mental health crisis that requires the program to call 911, a mental health crisis intervention team or a similar mental response team or service when available and appropriate An act or situation involving a client that requires program to call 911, law enforcement or the fire department Client unauthorized or unexplained absence Death of a client Describe Incident, Staff Response and Resolution of incident, including treatment given and client response (use additional sheets if necessary): Signature of Reporter Position/Title Internal Review, comments and corrective actions/written recommendations or service delivery changes