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Foster Care Incident Report
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Child's Name
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Date and time of incident
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Date and time reported
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Type of injury
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Type of injury
Injury - Self-inflicted
Injury - Accidental
Injury - Physical Aggression
Physical Aggression, Caregiver Assault
Physical Aggression, Peer Assault
Sexual Activity
Property Damage
Substance Abuse
Verbal Aggression
Alleged Abuse - Physical
Alleged Abuse - Sexual
Theft
Truancy
Runaway
Illness
Other
If you selected other, provide more information
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Factual description of incident (Who, what, when, where, why, etc...)
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State of mind of child at time of the incident (from your observations)
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Immediate action taken (describe remedy, others contacted, etc...)
Consequences (if applicable)
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Planned response in relation to treatment plan
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Could this incident have been prevented? If so, how?
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Digital signature of person describing incident
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Today's Date
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