SIR - Greenacre Homes & School

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Special Incident Report

* Indicates required field

Client's Name *

Client's Birthdate (e.g. 01/01/1995) *

Date of Incident (e.g. 01/01/2013) *

Time of Incident (e.g. 12:45 pm) *

Location of Incident *

Name(s) of Staff and Others Involved, Initials of other Clients involved (either directly or as a witness) *

Serious Incident: (mark all that apply) *

assault restraint AWOL (Supplement required) opportunity room > 1hr escort property damage > $100 serious self injury ISB (with contact) hospitalization police or emergency services called CPS report submitted

Serious Incident (Other) *

Incident: (mark all that apply) *

opportunity room non-contact ISB aggressive behavior sickness or injury property damage medication error major tantrum/disruption stealing

Incident (Other) *

Mark All Interventions Attempted: *

Planned Ignoring Humor Counseling Nonverbal prompts Redirection Phone call to family/worker Giving directions Reminders of good choice & keeping problems small Changing out Staff Closing of bedroom door Distraction Use of timer Taking space Count down from 5 Separate client from others

Describe All Interventions Attempted: *

Briefly Describe Incident: *

Lead-up to Incident *

Description of Incident (include attempts to de-escalate) *

Physical Restraint Used: *

Basket Wall Prone

OC must be contacted at 30 minutes, SW or OC must supervise at 60 min. and OC must call PW. (OC = On-Call, PW = Placement Worker, AD = Administrator Designee)

Mark All Times Reached *

15 Min. 30 Min. (OC, AD or SW must be contacted ≥ 30 Min.) 45 Min. 60 Min. 75 Min. 90 Min.

Was OC, AD or SW contacted at 30 minutes? If so, what time and who did you contact? *

Opportunity Room Used: *

Yes No

Escorted: *

Yes No

OC must be contacted at 30 minutes, SW or OC must supervise at 60 min. and OC must call PW.

Mark All Times Reached *

15 Min. 30 Min. (OC, AD or SW must be contacted ≥ 30 Min.) 45 Min. 60 Min. 75 Min. 90 Min.

Was OC, AD or SW contacted at 30 minutes? If so, what time and who did you contact? *

Outside Agency Contacted: *

Yes No

Agency Name: *

Case Number: *

Client's Re-entry into program: *

Report Written By: (Staff Name) *

First

Last

Date: (e.g. 01/01/2013) *

Submit

Administration
438 Eddie Lane
Sebastopol, CA 95472
(707) 823-8722
www.greenacrehomes.org

School
7590 Atkinson Road
Sebastopol, CA 95472
(707) 829-1366

Home
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