Incident Report

Date of Report*
Staff Name*
First Last
Staff Email*
Client Name*
First Last
Date of Incident*
Time of Incident*

: HH

MM
Location*
Street Address Address Line 2 City Province Postal Code
Type of Incident Identified:*
- AWOL
- Allegation
- Aggression
- Property Damage
- Attempt Self-Harm/Injury
- Substance Abuse
- Disclosure
- Restraint
Precipitating Factors:*
Description of Incident (Detailed, include who was present):*
Strategies Used*
- Avoiding power struggle
- Cueing
- Labeling behavior
- Providing Information/direction
- Awareness of patterns and/or triggers
- Nurturing, caring gestures
- Positive Touch
- Humour
- Validating
- Active/Responsive Listening
- Removal of Negative Stimuli
- Warnings/limits/rules/guidelines
- Calming/Meditating Techniques
- Redirection
- Negotiation
- Choices
- Regrouping
- Problem Solving
- Program/Incentive Reminders
- Limit setting
- Confronting
- Planned ignoring, strategic
- Non-interference
- Disrupting Group Contagion
- Discussion/Counselling
- Extra Support and/or attention
- Staff directed time away/out
- Self-directed time away
- Removal of trigger
- Fines (allowance)
- Natural/Logical Consequence
- Verbal de-escalation
- Defusing
- Physical redirection (not considered a physical restraint)
- Rewarding Positive Behaviors
- Other, please specify______________________
Debriefing with Child/Youth (Include child's condition and response to the incident)*
Person’s notified
CAPTCHA