Incident Report — Open Grace LLC
Report incidents involving clients or operations promptly and accurately.
Reporting Staff Information
Reporting Staff Full Name
*
First Name
Last Name
Staff Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Email Address
*
example@example.com
Date of Report
*
-
Month
-
Day
Year
Date
Time of Report
*
Hour Minutes
AM
PM
AM/PM Option
Incident Details
Client Full Legal Name
*
UCI Number
*
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Please Select
Client Home
Community Setting
Open Grace LLC Vehicle
School or Day Program
Medical Facility
Other
Location of Incident - If Other, please describe
Incident Type
*
Please Select
Consumer Injury
Behavioral Incident
Abuse Allegation — Physical
Abuse Allegation — Emotional
Abuse Allegation — Sexual
Neglect Allegation
Medical Emergency
Medication Error
Property Damage
Unauthorized Absence — Elopement
Environmental Hazard
Staff Misconduct
Other
Incident Type - If Other, please describe
Incident Description
Detailed description of what occurred
*
What was the consumer doing immediately before the incident?
*
What triggered or preceded the incident?
Witnesses present — names and roles
Describe immediate actions taken
*
Emergency Response
Was 911 called?
*
Yes
No
What time was 911 called?
Hour Minutes
AM
PM
AM/PM Option
Was the consumer transported to a hospital?
Yes
No
Which hospital?
Was the consumer's guardian or family notified?
*
Yes
No
Who was notified and at what time?
Was Director Joshua Ellis notified?
*
Yes
No
What time was Director Joshua Ellis notified?
Hour Minutes
AM
PM
AM/PM Option
Was IRC notified?
Yes
No
IRC contact name and time
Mandated Reporting
Does this incident require a mandated report to APS or CPS?
*
Yes
No
Unsure
Has the report been filed?
Yes
No
In Progress
Report confirmation number
Follow Up
Recommended follow-up actions
*
Has consumer returned to a safe environment?
*
Yes
No
Unknown
Is ongoing monitoring required?
*
Yes
No
Additional notes or observations
Staff Attestation
Attestation Statements
*
I certify this report is accurate and complete to the best of my knowledge
I understand this report is confidential and may be reviewed by IRC
I understand I have mandated reporter obligations under California law
Staff Digital Signature
*
Date and Time Signed
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Acknowledgment
Certification Note
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