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(@B: $ $~ 45 Zڼ: hn:  4    `'#"l@@@@@B?@B: h | / aH: hz:  '    f*"H @@@B@B: x D) R4 9: h6:  *4    `,#"l@@``@B ( ( (? (@B: : 6 Js3 [O: ho:  ,CHNKINK 5TEXTTEXTh@STSHSTSHhBSTSHSTSHBSTSHSTSH>C<FDPPFDPPDFDPPFDPPFFDPPFDPPHFDPCFDPCJFDPCFDPCLFDPCFDPCNFDPCFDPCPFDPCFDPCRFDPCFDPCTFDPCFDPCVFDPCFDPCXFDPCFDPCZFDPC FDPC\FDPC FDPC^FDPC FDPC`NEW HAVEN YOUTH & FAMILY SERVICES, INC. Special Incident Report Residential Date: Facility Name: Site Address: State/License #: Phone #: Incident Date: Time: A.M. / P.M. Location: Child Involved: Sex: D.O.B.: D.O.E.: Staff Involved: Type of Incident: (Check as many as apply) AWOL Suicide Attempt Alleged Child Abuse Theft Substance Abuse School Incident Injury/Illness Hospitalization Physical Violence Police Involvement Juvenile Hall Sexually Related Incident Property Damage Missed Medication Staff Related Incident-*if reporting a staff injury you must contact HR and your supervisor. Other/Pro-Act DESCRIBE INCIDENT: Provide a detailed narrative, describing the incident and the events leading up to the incident, (who was involved, where the incident took place, all staff interventions and the resolution), and what actions were taken to re-integrate child into the general population after the incident. attach narrative to form and email narrative to your supervisor. THIS PAGE IS TO BE FILLED OUT ONLY IF A PHYSICAL INTERVENTION WAS USED! PHYSICAL INTERVENTION USED: ________YES ________NO Date and time of other physical interventions involving the same child in the past 24 hours: _____ Reason physical intervention was required: (Check as many as apply and provide explanation.) Danger to Self Explain: Danger to Others Explain: Risk of Serious Injury Explain: Physical interventions used and how long the child was restrained: Enter # of MINUTES for each intervention used: Capture Standing Restraint _______ Standing Escort _______ Escort Seated Restraint Wall-Assisted Restraint Floor-Assisted Restraint _______ Protected Separation Room Were any injuries sustained by resident? YES NO If YES, Type of medical treatment sought: MSC: Range of motion check completed: _____ YES; comments, plan of action and signature: ________________________________________________________________________________________________________________________________________________________________________________________________________ Description of the child s verbal response and physical appearance following physical intervention: _______ ______________________________________________________________________________________________ Interventions utilized prior to the use of physical interventions: (Enter # of times intervention was tried.) Crisis Counseling Redirection Ignoring Positive Reinforcement Time-Out Separation of Residents Modeling PRN Removal from Home Group Verbal Intervention Non-Verbal Cue Safety Zones Program Stop Behavioral Contracting Consequences Close Watch Constant Watch LSCI Conflict Cycle BSP BIP Other (Describe): ________________________________________________________________________ PRO-ACT Review: (this section is to be completed by a PRO-ACT certified trainer) Child presented imminent danger to self or others? YES NO Was risk presented by child s behavior greater than risk of harm from use of restraint? YES NO Restraint or other physical intervention conducted safely and properly? YES NO Did the physical intervention last for the minimum amount of time? YES NO Were sufficient preventative steps taken? ________ YES NO Did staff attempt at least two non-physical/non aversive interventions? _______ __YES _________ NO Did deescalation techniques cause an escalation of the child s behavior? YES NO Physical intervention used only after less restrictive techniques proven to be unsuccessful? YES NO Are appropriate follow up steps to prevent re-occurrence indicated for child? YES NO Pro-Act Reviewer Comments/Recommendations/Signature: _____________ ___________________________________________________________________________________________________ *Human Resources review of staff injury, safety recommendations and plan to prevent a re-occurrence of the incident: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Supervisor s Remarks: Number and/dates of similar reportable incidents ____________________ Commonalities (please note activity in which incident occurred, length of activity, people present, time of day, environmental pollutants, antecedent, physical state and another commonalities between this and similar incidents): ______ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ISP, BSP or BIP: If the child has been involved in previous similar incidents, explain what previous modifications were done to the child s ISP, BSP, BIP and/or milieu. ________________________________________________________ Treatment recommendations: ________________________________________________________________________________ Staff Corrective Action or program modification to prevent the re-occurrence of any problem (if applicable): __________________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ NHYFS SIR-Pg. 2 NHYFS 3/06 NHYFS SIR-Pg. 3 RUNAWAY(AWOL): ________ YES ________NO Time the child s absence was first noted? A.M. / P.M. How was it determined? The child s last known activities: What were the circumstances surrounding the child s absence: What actions did staff take to discourage the child from leaving, and what interventions were utilized, if any: _______ What action was taken, at what time, by staff to locate the child: LAW ENFORCEMENT: YES NO If YES, why was their assistance necessary? (Check as many as apply and provide explanation.) Danger to Self Explanation: Danger to Others _________________________________________________________ _______ Runaway ________Illegal Conduct _________________________________________________________ Notification Verification: P/W/F * Date Person Contacted Contacted By Parent/s, Guardians Police Report # Placement Worker Licensing Worker Probation Officer Child Abuse Report (CPS) School District Other PRINT NAME SIGNATURE DATE Staff Writing Report: ________________________________________ ________________________________ _____________________ Program Specialist: Residential Director: Program Director: Please draw a diagram of each physical intervention and label all staff and residents who were involved. u11G ""$$h ,9"D "0(1||urrence of any problem (if applicable): ________________________KP8Rd"$LNZ\|~.0LN ( <\2dX8z8|` 4"b  4"5%4"5%N~$& (!!"l#$$%&)f*+j,,.t/J02244t5@6B6b6x666r77889R::F;;L<<`======>> >">$>F>H>J>L>N>p>r>t>v>x>>>>>>>>>>>?? 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