Incident/Accident Report Form
Incident/Accident Report Form
This report is to be used when accidents (client falls or otherwise is harmed during a 360 Blueprint activity) or incidents of dangerous behavior as well as for suspected child/elder abuse, neglect and endangerment. All reports are to be signed by the Executive Director and then copied. The copy will go in the client"s hard file and the original will stay with the Executive Director.
Description of Incident/Accident
Client Name:
Address:
Home Phone:
Description of Incident/Accident with Date and Time:
Staff/Volunteer Statement:
Was a Parent/Family Member Contacted?
YES
NO
Time and Date:
-
Month
-
Day
Year
Date
Reporting of Chid/Elder Abuse, Neglect, Endangerment
Date and Time Reported:
Reported by calling 1-800-992-575(CPS), or any other Child Welfare agency (for immediate response only, for other issues, use the online form)
Reported via the Suspect Child Abuse Form
found on the Nevada Department of Health
and Human Services website:
http://www.dcfs.state.nv.us
Intake Workers Name:
Documentation #
Intake Worker"s I.D. #:
Date Sent:
-
Month
-
Day
Year
Date
Was a report taken?
YES
NO
Call I.D.#
Staff/Volunteer Name (PRINT)
Supervisor Signature
Staff/Volunteer Signature
Executive Director Signature
Submit
Should be Empty: