Incident/Accident Report Incident/ Accident Description – Give detailed information about the occurrence Contact Name Email Are you only reporting or also involved?:--None--Contact is Reporting Only Contact is Involved in Incident/Accident Date of Incident/Accident: Time of Incident/Accident: Facility Location:--None--Oakland Service Center Claire's House Concord Service Center West County Service Center Verde Elementary Other Incident/Accident Location if not CCEB: Program/Department: --None-- All Programs Claire's House CRSN Day Star Development Experience Hope for Teens Experience Hope in Communities Experience Hope in Schools Facilities Family Literacy Program Finance Grants Housing Services HR IT Legal Immigration Mental Health Path 2 Quality Assurance Reception and I&R TRUE Academy Volunteers Other Type of Incident/Accident (Items marked with ** are considered critical and require involved individuals to be debriefed.): (To select multiple items, press and hold Ctrl or Cmd while clicking the items.): APS/CPS Report** Controlled Substance Usage Facilities: Alarm/Building Security Issue Facilities: Broken Equipment or Furniture Facilities: Fire or Electrical Hazard Facilities: Liquid/Chemical Spill or Leak Facilities: Structural Safety Risk Facilities: Tripping/Fall Hazard General Physical Aggression or Violence** Mental or Emotional Distress** Other Illegal Activity Physical Abuse or Neglect Physical Injury** Police Report** Property Damage Security/Confidentiality Breach** Stolen/Lost CCEB I.T. Equipment (phone, laptop, etc)** Stolen/Lost CCEB Property (except I.T. Equipment) Theft (non-CCEB property)** Vandalism Vehicle Accident** Verbal Abuse or Threat** Other Detailed Incident/Accident Description: Primary Individual Involved: Address of Individual Involved: Category of Individual:--None--Client Employee Volunteer Visitor Gender:--None--Female Male Transgender Female Transgender Male Other Individual is a Minor: Phone of Individual Involved: Email of Individual Involved: Additional Individual Involved (1): Address/Phone/Email of Individual (1): Category of Individual (1):--None--Client Employee Volunteer Visitor Gender (1):--None--Female Male Transgender Female Transgender Male Other Individual is a Minor (1): Additional Individual Involved (2): Address/Phone/Email of Individual (2): Category of Individual (2):--None--Client Employee Volunteer Visitor Gender (2):--None--Female Male Transgender Female Transgender Male Other Individual is a Minor (2): Additional Individual Involved (3): Address/Phone/Email of Individual (3): Category of Individual (3):--None--Client Employee Volunteer Visitor Gender (3):--None--Female Male Transgender Female Transgender Male Other Individual is a Minor (3): Additional Individual Involved (4): Address/Phone/Email of Individual (4): Category of Individual (4):--None--Client Employee Volunteer Visitor Gender (4):--None--Female Male Transgender Female Transgender Male Other Individual is a Minor (4): Witness #1: Witness #1 Phone: Witness #1 Email: Witness #2: Witness #2 Phone: Witness #2 Email: Important Note: If the Incident/Accident Type is deemed "Critical" (as noted with ** in the picklist), a debrief of the individuals involved is required. Please answer the following three questions about debriefing accordingly. Was a Critical Incident stress debriefing conducted with the staff involved?:--None--Yes No Declined to Answer Not Asked Not Applicable Was a Critical Incident stress debriefing conducted with the client(s) involved?:--None--Yes No Declined to Answer Not Asked Not Applicable Describe any quality improvements for the Agency that were identified from the debrief(s): Law Enforcement was Notified: Date Law Enforcement Notified: Law Enforcement Agency & Contact Name #1: Law Enforcement Agency & Contact Name #2: Police Report Filed (submit copy): APS/CPS was Notified: Date APS/CPS Notified: APS/CPS Agency & Contact Name #1: APS/CPS Agency & Contact Name #2: APS/CPS Report Filed (submit copy): Healthcare Provider was Notified: Date Healthcare Provider Notified: Healthcare Provider & Contact Name #1: Healthcare Provider & Contact Name #2: Parent/Legal Guardian was Notified: Date Parent/Legal Guardian Notified: Parent/Legal Guardian Name #1: Parent/Legal Guardian Name #2: Direct Supervisor was Notified: Date Direct Supervisor Notified: Direct Supervisor Name: Other Notification Comments:
