CDAC Internal Use Incident Form Programs*WISERISE-EscambiaRISE-SRECHOECHO-PPGBOOSTPreventionAdministrationDate* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Location*Client ID/#*NO CLIENTS NAMEReported by:*your first name last nameNotifications-1* Protective Service Supervisor/Director Executive Director Parent/Gaurdian Law Enforcment Date of Notification-1* MM slash DD slash YYYY Time of Notification-1* : Hours Minutes AM PM AM/PM Notifications-2* Protective Service Supervisor/Director Executive Director Parent/Gaurdian Law Enforcment Date of Notification-2* MM slash DD slash YYYY Time of Notification-2* : Hours Minutes AM PM AM/PM Type of Incident* Extreme - Abuse/neglect/Exploitation Please call 1-800-962-2873 (1-800-96-ABUSE) Extreme - Client injury or ill (Hospital Admission) Extreme - Altercation – Medical Care Needed Extreme - Negative Media Issue Extreme - Client Death Extreme - Elopement Extreme - Escape Extreme - Suicide Attempt Extreme - Client to client Sexual Battery Extreme - Other --Brief Descript in the text box below-- Moderate - Client Grievance Moderate - Witnessed client illness/injury (ER released) Moderate - Witnessed client illness/injury (1st aid or less) Moderate - Physical Altercation 1st aid or less, between client or with staff) Moderate - Threats by client(s) –If immediate danger, treat as Extreme, under other Moderate - Active suicide Ideation/Threat Moderate - Other --Brief Descript in the text box below-- Staff - Vehicle Accident while on Duty – accident with injury treat as Extreme, under Other (must also complete drug/alcohol tests, see P&P 801) Staff - Damage of Personal or Agency’s property Staff - Theft of Personal or Agency property Staff - Employee injury – Must also do Worker’s Com report Staff - Other --Brief Descript in the text box below-- Brief Description of Incident* Δ