Katie Hurstwicker's Site

Email *

Date of Incident *

Time of Incident *

Member Name (Last, First, M.I.)

Member’s Date of Birth:

This Information is are available for review in the client's profile in vTrack. If you have difficulty finding it, please contact the admin team for support.

Is this Member in Foster Care?

*

Is a Behavior Plan required?

* This Information is are available for review in the client's profile in vTrack. If you have difficulty finding it, please contact the admin team for support.

If yes, is the Behavior Plan current?

If no, Skip

Yes

No

N/A

If yes, Expiration Date: If no, Skip

Is there a current Person-Centered Service Plan (PCSP)?

PCSP are available for review in the client's files in vTrack. If you have difficulty finding it, please contact the admin team for support.

If yes, PCSP Date:

* PCSP are available for review in the client's files in vTrack. If you have difficulty finding it, please contact the admin team for support.

If yes, Does the PCSP identify the need for an enhanced ratio?

* PCSP are available for review in the client's files in vTrack. If you have difficulty finding it, please contact the admin team for support.

If yes, select appropriate supervision level:

If no, Skip.

1 : 1

2 : 1

Qualified Vendor or Provider responsible for Member at the time incident occurred:

Vendor Name

* Arizona Lionhearts

Site Name:

For Example: Member's home, In community setting such as a park, store, restaurant, etc.

Site Address

* physical address of incident. For Example: the corner of Elliot and Higley in Gilbert, AZ; 1234 Main St. Chandler, AZ

Location of Incident:

*

Group Home

Day Treatment Adult

Day Treatment Child (After School/Summer)

Family Home

Intermediate Care Facility (ICF)

Employment Program

Individually Designed Living Arrangements

Developmental Home

School

Reporting Provider Name:

Your Name

Job Title

For example: Direct Care Worker, Speech therapist, Supervisor

Phone Number

Individual / Staff Involved #1: Individual / Staff involved in incident (Last, First, M.I.):

*

Immediate Supervisor

* An Arizona Lionhearts admin staff

Immediate Supervisor Phone Number

* 480-253-9377

If applicable, Individual / Staff Involved #2: Individual / Staff involved in incident (Last, First, M.I.):

Immediate Supervisor of staff #2

Immediate Supervisor of staff #2 phone number

If applicable, Individual / Staff Involved #3: Individual / Staff involved in incident (Last, First, M.I.):

Immediate Supervisor of staff #3

Immediate Supervisor of staff #3 phone number

Incident Report

Incident Report

Incident Report