Foster Families & HCTC Families:

Incident Reports Writing Instructions
Foster Families & HCTC Families:
According to CFC’s policy, all incidents must be verbally reported to your
licensing worker, their supervisor, or through the emergency cell phone
within 24 hours, except in cases outlined below by Article 58, which
requires reporting within 2 hours. A written report, on CFC form 9004-1,
must then be completed and turned in to the appropriate staff within 24
hours.
When completing incident reports please remember that you must follow the
guidelines set out by Article 58, which states:
R6-5-5834 Notification of Foster Child Death, Illness, Accident, Unauthorized
Absence, or Other Unusual Events
A. Within 2 hours after a foster child suffers any of the following events, a
foster parent shall notify a child’s placing agency [CPS]
1. Death;
2. Serious illness or injury requiring hospitalization or emergency room
treatment;
3. Any non-accidental injury or sign of maltreatment;
4. Unexplained absence;
5. Severe psychiatric episode;
6. Fire or other emergency requiring evacuation of the foster home;
7. Removal of a foster child from the foster home by any person or agency
other than the placing agency, or attempts at such removal; and
8. Any other unusual circumstance or incident which might seriously affect
the health, safety, or the physical or emotional well-being of a foster
child
B. Within 48 hour of occurrence, a foster parent shall notify the placing agency
of any other events likely to affect the well-being of a foster child in the
foster parent’s care, including the following circumstances:
1. Involvement of a foster child with law enforcement authorities;
2. Serious illness or death involving a member of the foster family’s
household or a significant person;
3. Change in foster family or household composition; and
4. Absence of 1 foster parent from a 2 parent household for more than 7
continuous days.
C. Within 24 hours of giving notice as prescribed in subsection (A) or (B), a
foster parent shall send the placing agency and licensing agency a written
report on the event. The report shall include the following information:
1. A description of the event, with the date and time of occurrence;
2. The names and telephone numbers of any persons involved in the event;
3. Any measures taken to address, correct, or resolve the event, including
treatment obtained, and persons notified.
Christian Family Care INCIDENT REPORT
IDENTIFYING INFORMATION: (Writer, please print CLEARLY and LEGIBLY. State N/A, if appropriate.)
Today’s Date:
Date & Time of Incident:
Agency
Phx
Tuc
Date:
Program:
Admin (in office)
Admin (Thrift Store)
Counseling
Foster Care
HCTC
Time:
AM
Adoption
Pregnancy
PM
Writer, please document the location of the incident, including address:
Person Writing Report Name
Contact Phone
If client: Date of Intake:
Diagnosis,:(required for OBHL or OLCR reporting only)
OBHL License: BH-1514
Subclass: Counseling Outpatient
Child Client’s Name (Last, First, M.I.)
N/A
Parent / Guardian / Foster Parent’s Name (Last, First, M.I.)
N/A
Date of Birth
(please circle appropriate title, above)
Case Manager’s Name (Last, First, M.I.)
N/A
Staff / Consumer / Adult Client’s Name (Last, First, M.I.)
N/A
(please circle appropriate title, above)
BRIEF DESCRIPTION OF INCIDENT AND LOCATION
Physical and mental description of client prior to and after the incident:
Witness(es) present at the time of the incident (if a client, please use first
name and initial, only):
ACTION TAKEN (First aid, hospitalization, etc.)
INTERVENTION: (Writer, please check ALL that apply.) CPS Office: 1-888-767-2445, Fax: 602 530-1832; OBHL Office: 602 364-2595, Fax: 602 364-4801
CFC Caseworker notified
DES/RBHA Caseworker notified
Notes:
Name of person:
(Check appropriate box above)
Date:
Name of person:
Time:
Date:
CFC Supervisor notified
Time:
Name of person:
Fire Department notified
Date:
OBHL notified/faxed – Date:
Time:
OLCR notified – Date:
CPS/APS notified – Date:
Parole/probation notified
Person contacted:
Police notified (Rpt #
)
Faxed date:
Crisis Services notified
Other (Specify)
Writer's Signature:
Printed Name & Title
P:\FORMS\ADMIN\9004-1 fielded
Initiated: 2000 Most recent revision: 6/22/2012 Printed: 3/4/13\5:06 PM
(update form #6086 AND cfc website)
Date:
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