Incident and Participant Status Update Report (WY)
Participant Name
*
First Name
Last Name
Date of Report
*
-
Month
-
Day
Year
Date
Office Location
*
Cheyenne
Casper
Client Services Field Supervisor (CSFS) Name
Sean Archer
Kristy Romero
JJ Sanchez
Amiela Bell
Client Services Field Supervisor (CSFS) Name
Josh Fowler
Lindsey Tempest
Name of Person Completing this Form
*
First Name
Last Name
Type of Report
Incident Report (State Reportable)
Seizure Report
Health Status Report
Behavior Status Report
General Status Report
Daily Activity Report
Date and Time Event Occurred:
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Month
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Day
Year
Date
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Hour
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Minutes
AM
PM
AM/PM Option
Location of Event
*
Participant's Home
Community
Other
Incident Report Type: (Used to report incidents as defined by State Critical Reportable Standards)
Suspected Abuse
Suspected Self Abuse
Suspected Neglect
Suspected Self-Neglect
Suspected Exploitation
Suspected Abandonment
Police Involvement
Crime Committed by a Participant
Injuries Caused by Restraints
Serious Injury
Death
Elopement
Intimidation
Sexual Abuse
Emergency Use of Restraints
Medical/Behavioral Admission
Medication Error
Other Injury
Seizure Report Type: (Used for Reporting Seizure Activity)
Seizure Activity
Date Seizure Occurred:
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Month
-
Day
Year
Date
Time Seizure Started and Ended
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Hour
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Minutes
AM
PM
AM/PM Option
Until
until
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11
12
:
Hour
00
01
02
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59
Minutes
AM
PM
AM/PM Option
What was Participant doing before the seizure began?
Describe the environmental conditions at time of seizure (noise, lighting, temperature, etc.)
Did Participant know s/he was going to have a seizure?
Yes
No
If yes, Did s/he: (Check All that Apply)
Hear Things
Smell Things
Feel Things
Taste Things
See Things
Unknown
Other
Was there a warning that s/he was about to have a seizure?
Yes
No
If yes, Did s/he: (Check All that Apply)
Crying Out
Acting Peculiar
Acting Sick
Irritable / Disagreeable
Unknown
Other
Observation of Body Part Seizure Began in (Check all that Apply)
Seizure began with head to right
Seizure began with head to left
Seizure began with head up and back
Seizure began with head forward on chest
Seizure began with eyes to right
Seizure began with eyes to left
Seizure began with eyes shut
Seizure began with eyes rolled up
Seizure began with eyes open / staring
Body Stiffness / Jerking Observed During Seizure (Check all that Apply)
Stiffness in right arm
Stiffness in right leg
Stiffness in left arm
Stiffness in left leg
Body arch
Twitching / jerking of right eyelid
Twitching / jerking of left eyelid
Twitching / jerking right face
Twitching / jerking left face
Twitching / jerking right arm
Twitching / jerking left arm
Twitching / jerking right leg
Twitching / jerking left leg
Activity Exhibited During Seizure (Check all that Apply)
Vomited
Nauseated
Unconscious
Spoke during seizure
Impaired speech
Limp
Incontinent (urine)
Incontinent (bowel)
Fell forward
Fell backward
Fell left
Fell right
Atonic (like a dishrag)
Tonic (like a log)
Face turned white
Face turned blue
Face turned red
Froth/Drooling
Blood stained froth
Tongue bitten
Did participant perform any unusual acts? If so which ones? (Check all that Apply)
No unusual Acts Performed
Wandering about
Act as if searching for something
Laugh
Run
Cry
Undress
Want to fight
Talk or mumble
Make rubbing, plucking, patting or other hand motions
Make chewing, spitting, smacking movements with mouth
Activity Following Seizure (Check all that Apply)
Remembered Seizure
Did Not Remember Seizure
Injured during seizure
Not injured during seizure
Drowsy
Vomited
Combative
Alert
Agitated
Resumed act
Confused
Nauseated
Deep Sleep
Headache
Week
Was Physician notified of Seizure
Yes
No
Was Participant Taken to Hospital
Yes
No
Was Participant Admitted to Hospital
Yes
No
Health Status Report Type: (Used to report change in physical condition or mental status, administration of PRN medication or First Aid, unusual events, illness, etc.)
Change in physical condition
Change in mental status
Administration of PRN medication
Administer First Aid
Illness
Unusual Event
Behavior Status Report Type: (Used to report all aggression, self injury, disruption, teasing, elopement, property damage, intimidation or other behavioral occurrences)
Physical Aggression
Verbal Aggression
Self Injury
Disruption
Teasing
Elopement
Property Damage
Intimidation
Antecedent (What was happening prior to the event?)
*
General Status Report Type: (Used to report information to team that does not fall into any other category)
Important Information for Team
Describe the entire event with as much detail as possible including what was happening prior to event, any action taken and what happened after the event.
*
Consequence (What happened following the event or as a result of the event?)
*
Daily Activity Report Type: (Used to daily activity when requested)
Parent/Guardian Communication
Summary of Daily Activity
Other Daily Information Requested
Signature of Staff Submitting Report
OFFICE STAFF ONLY
Follow up information should ONLY be completed by Bridges of Wyoming CSFS
FOLLOW UP: (Please type follow up information followed by CSFS name)
Submit
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