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Incident Report
Incident Level
Level 1
Level 2
Level 3
1. Type of service
Adult - Mental Health
Adult - Substance Abuse
Other
If Other, explain
2. Location of Incident
Residential
Outpatient
Inpatient
Partial Hospital Program
Other Day Program
Other (e.g. office, private residence)
If Other, explain
3. Client Name
4. Date of Birth
5. Client Address
City
State/Province/Region
ZIP/Postal Code
Country
United States
6. Date of Incident
Time
7. Client Phone Number
7a. Name of Reporting Agency
8. Name, Title and Phone Number (of person filing report)
9. Agency/program where incident occurred (if different from box 7a) report)
10. Location/address where incident occurred (if different from box 9)
Address
City
State/Province/Region
ZIP/Postal Code
Country
United States
11. Other witnesses to the incident
12. Indicate type of incident (check all that apply)
Death of a Client
Homicide committed by Client who is receiving services or has been discharged within 30 days
Suicide attempt (with or without medical attention)
Act of violence requiring medical intervention (includes intervention provided by staff nurse or physician), by or to a Client
Alleged or suspected abuse (physical, sexual, financial or verbal) of or by a Client
Adverse reaction to medication and/or medication error administered by a provider
Neglect resulting in injury or hospital treatment
Any sexual contact involving a minor (includes peer to peer contact)
Restraints (physical, mechanical, and/or chemical)
Seclusion
Police involvement or arrest (excludes involuntary commitments)
Fire, flood, or serious property damage at a site where behavioral health services are delivered or a facility where Clients reside.
Any physical ailment or injury that requires medical attention at a hospital on an emergency, outpatient or inpatient basis (including visits to urgent care).
Contraband found on facility premises (illicit substances or synthetic cannabinoids)
All non-routine discharges from inpatient, residential rehab (D&A), children’s residential, detoxification, or Medication Assisted Treatment - i.e., administrative/involuntary discharges or leaving a facility against medical or facility advice (AMA, AFA, AWOL)
Infectious disease outbreak at a provider site
Missing person: child/adolescent who has not returned home or facility within 4 hours or an at-risk adult who has not returned home within 24 hours (includes filing a police report)
Staff Issue (Office, Clinical, Administrative)
Alleged or suspected abuse (physical, sexual, financial or verbal) in the household of a client
Other
If Other, explain
13. Summarize the incident. Include precipitating factors, current status, and a description of any injuries, medical condition, (if applicable)
14. Describe any corrective actions taken at the time of the incident
15. Which of the following persons were notified by telephone?
Enter Name of Person, Phone #, Date, Time
Psychiatrist
Family/Significant Other
Case Mgr. or Therapist
Supervisor
Executive Director or Designee
Police
Fire Dept.
DCFS/ChildLine
ODMHS
Other agency
If Other, explain
16. E-Signature of person completing report
Date
Submit Report
