STATE OF DELAWARE



FORMCHECKBOX Making 3rd Party Report FORMCHECKBOX Revised Event Summary Last NameFirst NameMiddle InitialDate of Birth FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date of EventTime of EventLocation of Event FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider NameType of ServiceAdmission Date FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider Address:Street CityStateZipProvider Phone # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????1stHand3rd PartyEVENT TYPE (Check all that apply)Events requiring person-to-person voice contact. FORMCHECKBOX FORMCHECKBOX Allegation of institutional abuse of a Delaware child by (check one) FORMCHECKBOX program staff member or FORMCHECKBOX foster/adoptive parent(s) FORMCHECKBOX FORMCHECKBOX Alleged sexual assault or abuse of or by a Delaware child: Delaware youth is (check one) FORMCHECKBOX Suspect FORMCHECKBOX Victim FORMCHECKBOX FORMCHECKBOX Death of (check one) FORMCHECKBOX Child/youth, FORMCHECKBOX provider staff while on duty or FORMCHECKBOX foster/adoptive parent(s) FORMCHECKBOX FORMCHECKBOX Escape, AWOL or runaway from any (check one) FORMCHECKBOX 24-hour facility, FORMCHECKBOX foster/adoptive care, FORMCHECKBOX home pass or FORMCHECKBOX non-residential service program FORMCHECKBOX FORMCHECKBOX 5.Injury, illness or event requiring medical or psychiatric hospital admission beyond emergency room FORMCHECKBOX Admitted from any 24 hour placement FORMCHECKBOX Reported to Hotline Current Medical Condition: FORMCHECKBOX Stable FORMCHECKBOX Observation FORMCHECKBOX Critical (Detail ongoing Police investigation and officer/department in Description of Event section) FORMCHECKBOX FORMCHECKBOX 6.Disturbance that has the potential for harming a child or causing major program disruption such as a natural disaster, bomb threat, hostage taking, etc. FORMCHECKBOX FORMCHECKBOX 7. Abduction of youth - (check one) FORMCHECKBOX Provider/Program Facility FORMCHECKBOX Non-Provider/Program Facility FORMCHECKBOX Other Events for which voice mail messages are acceptable. FORMCHECKBOX 8.Arrest of an employee for criminal offenses occurring at the program site FORMCHECKBOX Involving a Delaware child FORMCHECKBOX municable disease of any child or staff in program (e.g., tuberculosis, hepatitis, meningitis) FORMCHECKBOX 10. Community, facility or employee issues which (check one) FORMCHECKBOX Do FORMCHECKBOX Do not directly involve a Delaware child, but could lead to media attention or inquiries (e.g., employee strike, protests about program location) FORMCHECKBOX 11.Contraband (e.g., weapons, drugs, and other illegal or dangerous items) FORMCHECKBOX 12.Infection/illness that may have been caused by conditions in the program facility FORMCHECKBOX 13.Injury or illness that results in emergency room visit or requires outside medical attention (exclude follow-up appts) FORMCHECKBOX 14.Medication error/lapse – Responsible Party (check one): FORMCHECKBOX Parent/Guardian FORMCHECKBOX Pharmacy FORMCHECKBOX Staff FORMCHECKBOX Other FORMCHECKBOX 15.Pattern of self-harm FORMCHECKBOX 16.Police called for assistance with youth or youth arrested on new delinquency charges Result: FORMCHECKBOX Charges Pressed FORMCHECKBOX No Arrest FORMCHECKBOX Youth transferred to Detention FORMCHECKBOX 17.Removal of employee from duty as a result of a performance issue that may affect security or child safety (i.e., intoxication or drug use while on duty, etc.) FORMCHECKBOX 18.Restraint (specify type of restraint) FORMCHECKBOX Mechanical FORMCHECKBOX Chemical FORMCHECKBOX Physical If Physical indicate type (check one) FORMCHECKBOX Prone, FORMCHECKBOX Standing, FORMCHECKBOX Sitting, FORMCHECKBOX Redirect, FORMCHECKBOX Other FORMCHECKBOX 19.Injury resulting from physical restraint FORMCHECKBOX 20.Seclusion FORMCHECKBOX FORMCHECKBOX 21.Suicide attempt FORMCHECKBOX 22.Provider vehicle accident involving (check one) FORMCHECKBOX Delaware client/child or FORMCHECKBOX family memberEvents to be reported to the DSCYF Contract Manager or Program Administrator only. FORMCHECKBOX 23.Allegation of institutional abuse lodged against provider’s staff but not involving a Delaware child FORMCHECKBOX FORMCHECKBOX 24.Allegation of abuse/neglect by non-agency person (parent, coach, etc)? FORMCHECKBOX 25.Arrest of provider staff for violent felonies against person(s) occurring away from the program site FORMCHECKBOX 26.Provider staff responsible for youth transportation charged with DUI (check one) FORMCHECKBOX On-duty or FORMCHECKBOX Off-duty FORMCHECKBOX 27.Physical peer to peer aggressionLast Name: REF Lastname \* MERGEFORMAT First: REF FirstName \* MERGEFORMAT DOB: REF DOB \* MERGEFORMAT Event Date: REF EventDate \* MERGEFORMAT Description of Event: Person(s) involved, situation preceding the event, action taken, outcome: FORMTEXT ?????Steps taken to evaluate or treat the child and assure child safety: FORMTEXT ?????If reporting restraint or Seclusion:Start Time: FORMTEXT ????? End Time: FORMTEXT ?????What are the implications of the event for change in the child’s treatment or case plan? FORMTEXT ?????What are the implications of the event for program or policy change(s)? FORMTEXT ?????Did event prompt a staff retraining? FORMCHECKBOX Yes FORMCHECKBOX No (Explain below) FORMTEXT ?????Is this an event that has or will be reported to the program’s licensing agency or accrediting body? FORMCHECKBOX Yes FORMCHECKBOX No (Explain below) FORMTEXT ?????If abuse or neglect by staff is alleged, has involved staff been removed from the direct child care setting? FORMCHECKBOX Yes FORMCHECKBOX No (Explain below) FORMTEXT ?????Last Name: REF Lastname \* MERGEFORMAT First: REF FirstName \* MERGEFORMAT DOB: REF DOB \* MERGEFORMAT Event Date: REF EventDate \* MERGEFORMAT CONTACT CATEGORYNAMECONTACT(Y / N)Phone/Voice Mail, Email or In Person? Include # If CalledDATETIMEChild/Client (for medication error) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Parent/Guardian FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Foster/Adoptive Parent(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DSCYF Case Manager FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DSCYF Program Administrator or Contract Manager FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DE Abuse Hotline FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DE Office of Child Care Licensing FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child Protection Agency (other state) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Police FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MOST RECENT CHILD/FAMILY CONTACT INFORMATIONFor events involving a child(ren) occurring in a non-residential service or program only, give the date and description of the provider’s most recent contact with the child(ren) prior to this Reportable Event.Date of last contactTime of contactPerson who made the contactHow was the contact made? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Description of contact: FORMTEXT ?????PERSON COMPLETING FORMI understand that DSCYF has the option of requesting additional and/or periodic written follow-up information regarding corrective actions, administrative investigations, policy or program changes, and/or a written Plan of Safety as a result of this Reportable Event.I affirm and attest that all information provided is complete and accurate to the best of my knowledge. Printed NameTitle FORMTEXT ????? FORMTEXT ?????Email Address (e-mail address where confirmation of receipt will be sent if submitting electronically) FORMTEXT ?????Signature (required if NOT submitting electronically)Date Report CompletedTime Report Completed FORMTEXT ????? FORMTEXT ?????Indicate contact person for additional information if different from above.Name: FORMTEXT ????? Title: FORMTEXT ????? Phone Number: FORMTEXT ????? ................
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