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