Serious Incident Report 2025

Name of Client*

First NameLast Name

Age of Client*

Name of Support Worker (Leave blank if you would like to remain anonymous)

First NameLast Name

Date of Incident*

Date

Time of Incident

Hour Minutes

AM/PM Option

Type of Incident*

Is any form of abuse connected to this incident?*

YesNo

DSP's have an important role as mandatory reporters to observe and report any form of abuse. Please review the website below and call this number if you believe any form of abuse has occurred: 855-503-SAFE (7233)

Oregon Mandatory Abuse Website

Name of Abused Individual(s)

If other individuals besides your client are also experiencing abuse please list their names

Nature and Extent of Abuse

Timelines, type of abuse, or known history. Please list type of abuse as well (Physical, emotional, neglect, financial, sexual, verbal, other)

Explanation or Evidence of Abuse

Please list any details or evidence you have witnessed or that has been shared with you by any individual experiencing abuse. Photos can be included if available at the end of this form.

Identity or Cause of Suspected Abuse

Name/Relation to client or others experiencing abuse

Please select all actions taken before or on this date:

Contacted Emergency Services (911)Contacted Authorities (Police, Child Protective Services, etc)Contacted Mandatory Abuse Reporting HotlineContacted Client's guardian or County Service CoordinatorProtective Measures

If you selected any boxes from the previous question, please provide additional details here:

Location of Incident*

Please describe what happened before the incident or leading up to it:*

Please provide a detailed description of the incident, including what you did:*

Description of injury if applicable:

Please list any other witnesses to the incident and their relation to the client:

Please describe any actions taken by yourself or others to prevent similar incidents in the future:*

Photo of Incident (Optional)