Incident Report (CO)
Name of Individual
*
First Name
Last Name
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Duration of Incident
*
Location of Incident
*
Was Control Procedure Used?
*
Yes
No
IF Control Procedure Used, Duration of physical Intervention
Type of Incident
*
Medical / Injury
Social / Behavioral
Other
Medical / Injury Type
Injury to Consumer
Medical Emergency
Hospitalization
Death of Consumer
Seizure of Unusual Nature
Medication / Charting Error
Alleged Mistreatment, Abuse, Neglect, Exploitation
Social / Behavioral Type
Lost or Missing Person
Aggression toward others
Self-injurious Behavior
Property Damage
Theft or Vandalism
Unusual Behavior
Emergency Control Procedure
Safety Control Procedure
Stolen Property of Persons Receiving Services
Other Type (Describe Incident in Detail)
Witnessed by
First Name
Last Name
Reported by
*
First Name
Last Name
Note Location of Injury or Pain
Configurable list
*
Was There Police Involvement?
*
Yes
No
IF Police Involvement, Case Number:
Description of Incident (FACTUAL INFORMATION ONLY)
*
Describe the events and environment leading up to the incident
*
How was the situation handled?
*
Was an Emergency Safety Control Procedure Used?
Yes
No
Starting Time Of Procedure
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Ending Time of Procedure
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Describe the procedure used.
Why was the procedure used.
Has this type of behavior occurred with this individual before?
Yes
No
Is it likely this type of behavior will recur?
Yes
No
Is there a behavioral ISSP?
Yes
No
Is the behavioral ISSP implemented?
Yes
No
Comments:
Measures to be taken or suggestions for preventing a reoccurrence of this incident
Report Written By:
*
First Name
Last Name
Date Report Written
*
-
Month
-
Day
Year
Date
Signature of Person Completing Report:
*
Bridges of Colorado Contract Manager
*
LaTasha Stephenson
Betty DeBoer
Amber Barger
TO BE COMPLETED BY SUPERVISOR
FOLLOW UP ACTION REQUIRED
Follow Up Action Requested
No Follow Up Necessary
IDT Meeting / Review Necessary
Additional Training Needed
Other
Comments:
Person Responsible for Follow Up:
First Name
Last Name
Follow Up Action Completed:
If Follow Up is not Completed in section above, indicate where documentation of follow up can be located:
Date Follow Up Completed
-
Month
-
Day
Year
Date
Signature of Person Completing Follow up
Submit
Should be Empty: