CLIENT INCIDENT REPORT

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GENERAL INFORMATION
Client's Name: Date of Birth:
Date of incident: Time Incident Began:
Program Involved:
Copies to be sent to:
CATEGORY
Medical Behaviour Accident Medication PRN Medication Physical Restraint

PERSONS NOTIFIED NAME DATE / TIME

Director/Manager:
Supervisor:
Internal Primary Worker:
Family:
Doctor/Hospital:
Other:

INTRUSIVE INTERVENTIONS (Physical Restraint, Behavioural PRN Medication)

PRN Medication administered: Yes No Time administered:

Physical Restraint Used: Yes No

If “Yes” individual is to be closely monitored and monitoring recorded every 15 minutes:

15 MIN 30 MIN 45 MIN 1 HR 1:15 HR 1:30 HR 1:45 HR 2 HR

Comments / Observations (Describe individual’s condition, mood, behaviour)

Record time entered and released from each control used for this specific crisis:

Other (please specify): to

to
to

Current BSP in place? Yes No

Are the interventions above described in the BSP?
Staff involved in intrusive interventions:

External Contact person informed: Yes No **REFER TO FACESHEET**

Name of contact person:

05/27/2016 OPS-100-20
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Antecedents (What happened before the incident?):

Setting events & potential triggers identified:

Location(s) of incident: (example: Kitchen)

Brief description of incident: (do not include any identifying information for other clients involved)

BEHAVIOUR
PROACTIVE STRATEGIES USED (CHECK ALL THAT APPLY):

Active listening Provided Choices Gave space Set limits Redirected

Verbal praise Distraction Removed desired object Ignored behaviour Allowed venting

Re-stated expectation Allowed time to process directive

Other:
CLIENT’S RESPONSE (CHECK ALL THAT APPLY):

Screaming Swearing Swing (no contact) Intimidation Hitting Spitting Leaving area
Pinching Kicking Scratching Biting Pushing Grabbing Throwing
SIB Other:

Was Physical Contact made: Yes No Staff Client Other:

DESCRIPTION OF RESPONSE ACTION TAKEN BY STAFF (CHECK ALL THAT APPLY):

Removed the Audience Called For Assistance CPI “Block and Move”

CPI Personal Safety Strategies:

Other Client Protective Measures:

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DEBRIEFING
Client debriefed: Yes No

Other debriefed: Yes No Staff Other client Other:

Debriefing conducted by: on

staff’s name date

Recommendations (to be completed by supervisor):

Submission date:

Staff completing report (name and signature):

Supervisor (name and signature):

Manager / Director (name and signature):