Criminal Justice

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Incident Report copied:_____

(PRIVATE Client Information)

Client: Client’s Unit: File #:

Date of Incident: Day of Week: Calm Room Use (check if used)

Time Incident Began: ____ a.m./p.m. (circle am or pm) Time Client Re-entered Programming: a.m./p.m.(circle one)

CHECK APPROPRIATE CATEGORIES THROUGHOUT ENTIRE REPORT

| |Aggressive Behavior w Property Damage | |Sexual Contact |

| |Suicidal Ideations &/or Serious Suicidal Concern | |Absence (Complete Return/Discharge Report) |

| |(See Suicide Prevention/Assessment Procedure) | | |

| |Aggressive Behavior Resulting in Time-Out | |Out of Supervision – (remained on grounds) |

| |(Complete Restrictive Intervention Report) | | |

| |Aggressive Behavior Resulting in | |

| |Therapeutic Hold (Complete Restrictive| |

| |Intervention Report) | |

Restrictive Techniques – Therapeutic Hold Information (Check and note all that apply)

| |

|___Time-Out...