Incident Report

It is the policy that all Foundation for Foster Children employees are required to report genuine concerns of misconduct and abuse within the Foundation, its staff, and to provide employees with a reliable means of doing so while at the same time ensuring protection against retaliation for such reporting. As it relates to Empower Advocates working in both the office and in the field with clients, the following matters should be reported in an incident report

Reportable matters include but are not limited to the following:

• Any situations that place an employee in a life-threatening scenario caused either by client, caregiver, client’s relative or other individuals working with the client.
• Physical and/or verbal abuse/assault towards an employee either by client, caregiver, client’s relative or other individuals working with the client.
• Threatening employee with physical abuse/assault either by client, caregiver, client’s relative or other individuals working with the client.
• Continual ongoing inappropriate language and behavior towards employee by a client, caregiver, client’s relative or other individuals working with the client.
• Contacting 911 and/or the DCF Hotline at 1 (800) 96-ABUSE
• Employee and/or client being injured.
• Reporting of past abuse disclosed by client if it was not mentioned and/or disclosed to the DCF Hotline at 1 (800) 96-ABUSE, case managers or child welfare agencies.

Employee Details
Name:*
Department/Position:*
Cell Phone Number:*
Client Name:*
Employee Signature:*
Description of Incident
Location of Incident*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Were police notified?*
- Yes
- No
Incident Details*
(How the incident occurred, factors that lead up to the issue, what took place, etc. Please be as specific as possible.)
Were there witnesses to the incident?*
- Yes
- No
Please list witness names, addresses, and phone numbers.
Follow-Up Recommendations*

Incident Report

Employee Details

Description of Incident