Incident Report

WHAT IS AN INCIDENT?

An incident is any situation, emergency, or interaction with a respondent that requires the interviewer to respond in a way different from or not covered by the routine protocols. Examples are current child or elder abuse, respondent’s intent to harm self or others, or an outburst on the part of a respondent.

WHAT IS THE PURPOSE OF THE INCIDENT REPORT?

The incident report documents non-routine situations that come up during data collection and provides senior evaluation staff with information to evaluate the need to act upon an incident.

____________________________________________________________________________________

Interviewer must complete PAGE 1 immediately after incident (w/help of supervisor, if needed).

DO NOT include any identifying information on pages 1 or 2 of this form.

Case ID:__________________________

Date of Incident: _____ / _____ / _____ Time of Incident: AM or PM

(circle)

Type of Incident (check all that apply):

 Current Suicidal Intent  Specific Intent to Harm Self (i.e., self-mutilation)

 Current Child Abuse  Specific Intent to Harm Other(s)

 Current Elder Abuse  Other, specify:

Record what respondent said VERBATIM (use notes taken during call):__________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any other relevant details about the incident (such as, but not limited to, referral #s given to R):

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Reported by (interviewer):______________________________________ Date: _____ / _____ / _____

Signature

Interviewer printed name: _______________________________________

DO NOT include any identifying information on pages 1 or 2 of this form.

TSC Supervisor Review (PAGE 2 to be filled out by supervisor as soon as possible after incident).

Confirmed by TSC Supervisor to be a current or specific threat?  Yes  No

If no, explain: ______________________________________________________________________

Additional notes from TSC supervisor’s monitoring/assessment of the incident (include any referral #s given to respondent not already noted above by interviewer): __________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RECORD OF ON-CALL CLINICIAN CONTACT (for suicidal and intent-to-harm incidents ONLY)

	Names of Clinician(s) Contacted	@ Phone # and/or Email address	Time Contacted	Outcome and Time of Outcome
1.			________ am ________ pm	______________ ________ am/pm
2.			________ am ________ pm	______________ ________ am/pm
3.			________ am ________ pm	______________ ________ am/pm

RECORD OF SURVEY DIRECTOR/COORDINATOR NOTIFICATION (for ALL incidents)

If applicable, was VMHSE staff emailed while waiting for return call from clinician? Yes  No  NA

If applicable, was VMHSE staff emailed after supervisor had spoken with clinician?  Yes  No  NA

Was Incident Report (Pages 1 & 2 ONLY) scanned and attached as PDF to email? Yes  No

Was Incident Report locked in VMHSE cabinet for director/coordinator review?  Yes  No

If NO is checked for ANY of the above four questions, explain: ­­­­­­­­­­­________________________________

____________________________________________________________________________________

Evaluation Team Review (to be filled in by Survey Director/Coordinator ONLY)

Date Survey Director/Coordinator received the report: _____ / _____ / _____

Action taken by Survey Director/Coordinator (indicate if consultation was with Principal Investigator, Mental Health Worker, Legal Counsel, or other AND describe conclusion of consultation): ­­­­­­­­­­­­

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Director/Coord. Signature: _________ Date Incident Resolved: _____ / _____ / _____

IDENTIFYING INFORMATION—PAGE 3—DO NOT SCAN OR EMAIL

TO BE DESTROYED ONCE INCIDENT RESOLVED

Respondent Name: ______________________________

Did respondent provide a best telephone number to be reached on currently?

 Yes. If yes, record #____________________________ (give to supervisor for clinician use)

 No

Did respondent provide current location?

 Yes. If yes, record location ______________________________

______________________________ (give to supervisor for clinician use)

 No

If the incident involves others, were you able to get their names?

 Yes. _____________________________________________________________________________

Name/Relationship/Role in incident for each person involved

 No. _____________________________________________________________________________

Any information that could help identify others involved.

 NA (Incident does not involve others)

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