LAW ENFORCEMENT CONTACT REPORT

IF MULTIPLE CHILDREN INVOLVED, FOLLOW DESIGNATION "C1" FOR CHILD 1 AND SO ON

AGENCIES/INDIVIDUALS NOTIFIED: C1

AGENCIES/INDIVIDUALS NOTIFIED: C2

AGENCIES/INDIVIDUALS NOTIFIED: C3

AGENCIES/INDIVIDUALS NOTIFIED: C4

WERE DE-ESCALATION TECHNIQUES USED PRIOR TO CONTACTING LAW ENFORCEMENT?
IF YES, EXPLAIN THE TECHNIQUES USED. IF NO, EXPLAIN WHY NOT.
WAS LAW ENFORCEMENT CONTACTED AS LAST RESORT ONCE ALL OTHER DE-ESCALATION AND INTERVENTION TECHNIQUES HAD BEEN EXHAUSTED?
WAS SUPERVISOR APPROVAL OBTAINED PRIOR TO CONTACTING LAW ENFORCEMENT?
IF NO, EXPLAIN WHY NOT.
LOCATION OF INCIDENT
IF OTHER, EXPLAIN WHERE
DESCRIPTION OF INCIDENT. INCLUDE NATURE OF INCIDENT, ACTION TAKEN BY STAFF IN RESPONSE TO THE INCIDENT, AND DISPOSITION OR CURRENT STATUS OF THE INCIDENT. FOR INCIDENTS IN GROUP HOMES, INCLUDE A DESCRIPTION OF THE EVENTS LEADING UP TO THE INCIDENT.
WAS MEDICAL TREATMENT REQUIRED FOR CLIENT?
IF YES, LIST NAME OF ATTENDING PHYSICIAN, FINDINGS, AND TREATMENT, IF ANY.
DOES THE INCIDENT INVOLVE THE USE OF MANUAL RESTRAINTS? IF YES, ATTACH A SEPARATE SHEET REPORTING INFORMATION REQUIRED BY SECTION 84061(h)(6)OF TITLE 22 REGULATIONS.
PREPARRED BY

NAMETITLE
DATE PREPARED

MonthDayYear
Date
REVIEWED/APPROVED BY

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DATE APPROVED

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PART 2
FACILITY
DATE OF INCIDENT

MonthDayYear
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DATE OF FOLLOW UP

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Date
WAS ANY CHILD RESIDING IN THE FACILITY ALLEGED TO HAVE COMMITTED A CRIME?

LIST ANY CHILD INVOLVED (WHETHER OR NOT ALLEGED TO HAVE COMMITTED A CRIME), INCLUDE CHILD(REN) FROM ORIGINAL INCIDENT (PART 1):

LIST ANY STAFF INVOLVED

WHO INITIATED CONTACT WITH LAW ENFORCEMENT?
TYPE OF OUTCOME

Other
(If any boxes above are checked, explain briefly here and include any additional information. Attachadditional sheets as needed.)
PREPARED BY

NAMETITLE
DATE PREPARED

MonthDayYear
Date
REVIEWED BY

NAMETITLE
DATE REVIEWED

MonthDayYear
Date
Signature
Should be Empty:

PART 1