Who is submitting this form?
Date of Incident
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Month
/
Day
Year
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Time of Incident?
Location of Incident?
Type of Incident
Medical Emergency
Altercation
Emergency Services Called
Harassment
Relapse
Property Damage
Threats
Theft
Injury on the premise
Conflict or Complaint from the Community
Program Non-compliant
Documentation
Who was directly involved?
Witnesses
Was anyone injured?
Yes
No
Were the authorities notified?
Yes
No
Give a full report of the incident here.
Outcome
Suggested next step for ERH Staff
No action needed / documentation
Formal write up / strike
Behavior contract needed
Discharge request
Needs further consideration / management review
Not sure
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ERH | Program Manager Status
Open - Needs action
Follow up - Details pending
Resolved - Documentation
Resolved - Behavior Agreement
Resolved - Discharge
Used to keep track of the status of all incident reports
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