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INCIDENT REPORTING

Frequently Asked Questions

"*" indicates required fields

SECTION I: PARTICIPANT INFORMATION

Provide the information below of the individual involved in the incident.
Your Name*
MM slash DD slash YYYY

HOUSEHOLD COMPOSITION

Individual’s relationship to the head of household*

Population*

(E.g. Tiny Homes, Inside Safe, PHK, Pathway Home, PSH, etc.…)

SECTION II: OCCURRENCE

OCCURRENCE INFORMATION

MM slash DD slash YYYY
Time
:
Address
(Participant Room, Lobby, Parking Lot)

If you were not present during the incident please include details below

When and how did you learn of the incident/accident?
MM slash DD slash YYYY
Time*
:
How were you notified*

TYPE OF INCIDENT*
Submissions of Photos are required.
Max. file size: 124 MB.

SECTION III: PARTIES INVOLVED

Name
Name
Name

SECTION IV: WITNESS INFORMATION

Name*
Address

Name*
Address

SECTION V: DETAILED DESCRIPTION OF INCIDENT(S)

Give specific factual accounts available during the first 12-hours of what occurred, who was involved, when and where it happened, why did it happen and how did the incident happen. Don’t forget to include applicable detailed information such as time of emergency notification was called, arrived and Officer’s/Medical I.D badge #, if anyone was taken to the hospital or refused medical attention, any damage to property, police report information, vehicle information etc.

For incidents that require contacting APS/DCFS/DPH, the following information must be included in this section:

SECTION VI: RESOLUTION

Give specific details of outcome that are available within the first 12-hours of the incident. (E.g., Indicate name(s) of outside agencies contacted, other action(s) taken, referrals made, etc.…) Please specify where those involved in the incident(s) are located currently. For incidents involving signs of abuse, neglect, trauma, or signs of contagious diseases, APS/DCFS/DPH guidance/recommendations must be included in this section. (Attach additional pages if needed.)

SECTION VII: STAFF INFORMATION

Submit all required Incident Report Forms to LAHSA within 12 hours of learning of the incident occurrence.
Completed By
MM slash DD slash YYYY
Time
:
Reviewed By
MM slash DD slash YYYY
Time
: