Incident and Participant Status Update Report (MT)
Participant Name
*
First Name
Last Name
Date of Report
*
-
Month
-
Day
Year
Date
Office Location
*
Billings
Missoula
Kalispell
Helena
Client Services Field Supervisor (CSFS) Name
*
Tanaya Heidt
Chris Turner
Jason Hill
Teri Wells
Name of Person Completing this Form
*
First Name
Last Name
Type of Report
*
Incident Report (State Reportable)
Health Status Report
Behavior Status Report
General Status Report
Date and Time Event Occurred:
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
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08
09
10
11
12
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50
51
52
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58
59
Minutes
AM
PM
AM/PM Option
Location of Event
*
Recreation / Leisure
Vehicle
Work
School
Family Home Visit
Unknown
Program
Other
Address where Event occurred:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Location where Event occurred:
-
Area Code
Phone Number
Incident Report Type: (Used to report incidents as defined by State Critical Reportable Standards)
Injury to Participant
Medication Error
Restraint related to Behavior
Restraint Other
Death
Other
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
General Status Report Type: (Used to report information to team that does not fall into any other category)
Important Information for Team
Antecedent (What was happening prior to the event?)
*
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?)
*
Signature of Staff Submitting Report
OFFICE STAFF ONLY
Follow up information should ONLY be completed by Bridges of Montana CSFS
Was Incident Entered in Therap?
Yes
No
Submit
Should be Empty: