Out-of-Home Care Provider Incident Report Instructions
This form contains 138 fields organized into 31 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Pages Attachment | ||
| Yes, Additional Pages Attached | Radiobutton |
Check this box if additional pages containing witness information are attached to this form.
|
| Child Abuse Hotline Notification Details | ||
| Hotline Notification Date | Date |
Enter the date the Child Abuse Hotline was notified. Fill only if is 'Yes'.
Depends on:
|
| Hotline Notification Time | Time |
Enter the time the Child Abuse Hotline was notified. Fill only if is 'Yes'.
Depends on:
|
| DCS Intake Specialist Name | Text |
Enter the name of the DCS Intake Specialist who was notified. Fill only if is 'Yes'.
Depends on:
|
| Contracted Agency Information | ||
| Contracted Agency Name | Text |
Provide the full name of the contracted agency or out-of-home care provider.
|
| Licensing Agency QCID | Text |
Provide the Quality Care ID (QCID) for the licensing agency, group home, or shelter, if applicable.
|
| Placed In Care | Radiobutton |
Check this box if the child or individual listed in this row was placed in care by the contracted agency.
|
| Placed In Care | Radiobutton |
Check this box if the child or individual listed in this row was placed in care by the contracted agency.
|
| Contracted Service Provider Notification | ||
| Name of Person Contacted | Text |
Enter the name of the person contacted for the contracted service provider. Fill only if 'Contracted Service Provider' is 'Yes'.
Depends on:
Contracted Service Provider
|
| Phone Number | Text |
Enter the phone number of the person contacted for the contracted service provider. Fill only if 'Contracted Service Provider' is 'Yes'.
Depends on:
Contracted Service Provider
|
| Date Contacted | Date |
Enter the date the contracted service provider was contacted. Fill only if 'Contracted Service Provider' is 'Yes'.
Depends on:
Contracted Service Provider
|
| Time Contacted | Time |
Enter the time the contracted service provider was contacted. Fill only if 'Contracted Service Provider' is 'Yes'.
Depends on:
Contracted Service Provider
|
| DCS Specialist/Supervisor Notification | ||
| DCS Specialist/Supervisor Name | Text |
Enter the full name of the DCS Specialist or Supervisor who was verbally notified. Fill only if 'DCS Specialist/Supervisor' is 'Yes'.
Depends on:
DCS Specialist/Supervisor
|
| DCS Specialist/Supervisor Phone Number | Text |
Enter the phone number of the DCS Specialist or Supervisor who was verbally notified. Fill only if 'DCS Specialist/Supervisor' is 'Yes'.
Depends on:
DCS Specialist/Supervisor
|
| Notification Date | Date |
Enter the date when the DCS Specialist or Supervisor was verbally notified. Fill only if 'DCS Specialist/Supervisor' is 'Yes'.
Depends on:
DCS Specialist/Supervisor
|
| Notification Time | Time |
Enter the time when the DCS Specialist or Supervisor was verbally notified. Fill only if 'DCS Specialist/Supervisor' is 'Yes'.
Depends on:
DCS Specialist/Supervisor
|
| Event or Incident Description | ||
| Incident Description | Text |
Provide a detailed account of the event or incident, including what happened before, during, and after, the child's mental and physical condition, and specific details about any injuries.
|
| Fifth Child/Individual Involved | ||
| Fifth Child Name | Text |
Enter the full name of the fifth child or individual involved, in the format Last, First, M.I.
|
| Fifth Child Participant ID | Text |
Enter the participant ID for the fifth child or individual if they are in DCS custody.
|
| Fifth Child Date of Birth | Date |
Enter the date of birth for the fifth child or individual involved.
|
| Fifth Child Placement Details | Text |
Enter the date the fifth child or individual was placed in care, and the provider/contractor address.
|
| Fifth Witness Information | ||
| Fifth Witness Name | Text |
Please provide the full name of the fifth witness, including their last name, first name, and middle initial.
|
| Fifth Witness Phone Number | Text |
Please provide the phone number for the fifth witness.
|
| Fifth Witness Relationship to Child(ren) | Text |
Please describe the relationship of the fifth witness to the child or children who are the subject of the report.
|
| Other | Checkbox |
Check this box if an additional contact, not listed above, was verbally notified regarding the incident.
|
| Other | Checkbox |
Check this box if an additional contact, not listed above, was verbally notified regarding the incident.
|
| First Child/Individual Involved | ||
| Child/Individual Name | Text |
Provide the full name of the child or individual involved in the incident, including last name, first name, and middle initial.
|
| Participant ID | Text |
Enter the participant's ID number, if the individual is in DCS custody.
|
| Date of Birth | Date |
Enter the date of birth for the child or individual involved.
|
| Provider/Contractor Address | Text |
Provide the full address of the provider or contractor associated with the individual.
|
| First Other Notification | ||
| First Other Contact Name | Text |
Provide the full name of the first other person contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| First Other Contact Phone Number | Text |
Enter the phone number of the first other person contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| First Other Contact Date | Date |
Provide the date when the first other contact was made. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| First Other Contact Time | Time |
Provide the time when the first other contact was made. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| First Witness Information | ||
| Witness Name | Text |
Enter the full name of the witness, including last name, first name, and middle initial.
|
| Witness Phone Number | Text |
Enter the phone number of the witness.
|
| Witness Relationship to Child | Text |
Describe the relationship of the witness to the child or children who are the subject of this report.
|
| Radiobutton |
|
|
| Radiobutton |
|
|
| Radiobutton |
|
|
| Fourth Child/Individual Involved | ||
| Fourth Child/Individual Name | Text |
Enter the full name of the fourth child or individual involved in the incident, in the format Last Name, First Name, Middle Initial.
|
| Fourth Child/Individual Participant ID | Text |
Enter the participant ID for the fourth child or individual, if they are in DCS custody.
|
| Fourth Child/Individual Date of Birth | Date |
Enter the date of birth for the fourth child or individual involved.
|
| Fourth Child/Individual Placed In Care Date | Date |
Enter the date the fourth child or individual was placed in care.
|
| Fourth Witness Information | ||
| Fourth Witness Name | Text |
Enter the full name of the fourth witness, including their last name, first name, and middle initial.
|
| Fourth Witness Phone Number | Text |
Enter the phone number for the fourth witness.
|
| Fourth Witness Relationship | Text |
Enter the relationship of the fourth witness to the child or children who are the subject of the report.
|
| Juvenile Probation/Parole | Checkbox |
Check this box if Juvenile Probation/Parole was verbally notified about the incident.
|
| Contracted Service Provider | Checkbox |
Check this box if a Contracted Service Provider was verbally notified about the incident.
|
| Other | Checkbox |
Check this box if an 'Other' contact (not explicitly listed above) was verbally notified about the incident.
|
| General | ||
| Signature | ||
| Signature | ||
| DCS Specialist/Supervisor | Checkbox |
Check this box if a copy of the written report was sent to the DCS Specialist/Supervisor.
|
| Date Sent to DCS Specialist/Supervisor | Date |
Enter the date the written report was sent to the DCS Specialist/Supervisor. Fill only if 'DCS Specialist/Supervisor' is 'Yes'.
Depends on:
DCS Specialist/Supervisor
|
| DCS Contracts | Checkbox |
Check this box if a copy of the written report was sent to DCS Contracts.
|
| Date Sent to DCS Contracts | Date |
Enter the date the written report was sent to DCS Contracts. Fill only if 'DCS Contracts' is 'Yes'.
Depends on:
DCS Contracts
|
| OLR/OLCR | Checkbox |
Check this box if a copy of the written report was sent to OLR/OLCR.
|
| Date Sent to OLR/OLCR | Date |
Enter the date the written report was sent to OLR/OLCR. Fill only if 'OLR/OLCR' is 'Yes'.
Depends on:
OLR/OLCR
|
| Licensing Agency | Checkbox |
Check this box if a copy of the written report was sent to the Licensing Agency.
|
| Date Sent to Licensing Agency | Date |
Enter the date the written report was sent to the Licensing Agency. Fill only if 'Licensing Agency' is 'Yes'.
Depends on:
Licensing Agency
|
| Juvenile Probation | Checkbox |
Check this box if a copy of the written report was sent to Juvenile Probation.
|
| Date Sent to Juvenile Probation | Date |
Enter the date the written report was sent to Juvenile Probation. Fill only if 'Juvenile Probation' is 'Yes'.
Depends on:
Juvenile Probation
|
| Other | Checkbox |
Check this box if a copy of the written report was sent to another entity not listed.
|
| Other Recipient | Text |
Specify the name or department of the other entity or individual to whom the written report was sent. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Date Sent to Other Recipient | Date |
Enter the date the written report was sent to the other specified recipient. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Incident Date and Time | ||
| Incident Date | Date |
Provide the date when the incident occurred.
|
| Incident Time | Time |
Provide the time when the incident occurred.
|
| Radiobutton |
|
|
| Radiobutton |
|
|
| Incident Location | ||
| Incident Street Address | Text |
Enter the street number and name where the incident occurred.
|
| Incident City | Text |
Enter the city where the incident occurred.
|
| Incident State | Text |
Enter the state where the incident occurred.
|
| Incident Zip Code | Text |
Enter the zip code for the incident location.
|
| Radiobutton |
|
|
| Juvenile Probation/Parole Notification | ||
| Juvenile Probation Parole Contact Name | Text |
Enter the full name of the person contacted from Juvenile Probation/Parole. Fill only if 'Juvenile Probation/Parole' is 'Yes'.
Depends on:
Juvenile Probation/Parole
|
| Juvenile Probation Parole Phone Number | Text |
Enter the phone number of the person contacted from Juvenile Probation/Parole. Fill only if 'Juvenile Probation/Parole' is 'Yes'.
Depends on:
Juvenile Probation/Parole
|
| Juvenile Probation Parole Notification Date | Date |
Enter the date the Juvenile Probation/Parole was notified. Fill only if 'Juvenile Probation/Parole' is 'Yes'.
Depends on:
Juvenile Probation/Parole
|
| Juvenile Probation Parole Notification Time | Time |
Enter the time the Juvenile Probation/Parole was notified. Fill only if 'Juvenile Probation/Parole' is 'Yes'.
Depends on:
Juvenile Probation/Parole
|
| Law Enforcement Notification Details | ||
| Officer Badge Number | Text |
Provide the badge number of the law enforcement officer. Fill only if is 'Yes'.
Depends on:
|
| Officer Name | Text |
Enter the full name of the law enforcement officer who was notified. Fill only if is 'Yes'.
Depends on:
|
| Law Enforcement Agency Name | Text |
Provide the full name of the law enforcement agency that was notified. Fill only if is 'Yes'.
Depends on:
|
| Police Report Number | Text |
Enter the police report number associated with this incident. Fill only if is 'Yes'.
Depends on:
|
| Licensing Agency Notification | ||
| Licensing Agency Person Contacted | Text |
Enter the full name of the person contacted at the Licensing Agency. Fill only if 'Licensing Agency' is 'Yes'.
Depends on:
Licensing Agency
|
| Licensing Agency Phone Number | Text |
Enter the phone number of the person contacted at the Licensing Agency. Fill only if 'Licensing Agency' is 'Yes'.
Depends on:
Licensing Agency
|
| Licensing Agency Contact Date | Date |
Enter the date the Licensing Agency was contacted. Fill only if 'Licensing Agency' is 'Yes'.
Depends on:
Licensing Agency
|
| Licensing Agency Contact Time | Time |
Enter the time the Licensing Agency was contacted. Fill only if 'Licensing Agency' is 'Yes'.
Depends on:
Licensing Agency
|
| Preparer Information | ||
| Preparer Title | Text |
Please enter the title of the person who prepared this report.
|
| Report Completion Date | Date |
Please provide the date when this report was completed.
|
| Preparer Name | Text |
Please enter the full name of the person who prepared this report, including last name, first name, and middle initial.
|
| Preparer Phone Number | Text |
Please enter the phone number of the person who prepared this report.
|
| Preparer Relationship to Child | Text |
Please describe the relationship of the person who prepared this report to the reported child who is in the custody of DCS.
|
| Prevention Steps Description | ||
| Prevention Steps Taken | Text |
Provide a detailed explanation of all actions taken to prevent the incident, including those before it occurred and any subsequent actions to prevent recurrence.
|
| Provider Information | ||
| Out-Of-Home Care Provider Name | Text |
Please provide the name of the out-of-home care provider.
|
| Licensing Agency/Group Home/Shelter Name | Text |
Please provide the name of the licensing agency, group home, or shelter, if applicable.
|
| Group Home Facility/Cottage/Casita Name | Text |
Please provide the name of the group home facility, cottage, or casita.
|
| Child 1 Placed in Care | Radiobutton |
Check this box if the first child or individual listed was placed in care.
|
| Child 2 Placed in Care | Radiobutton |
Check this box if the second child or individual listed was placed in care.
|
| Child 3 Placed in Care | Radiobutton |
Check this box if the third child or individual listed was placed in care.
|
| Reviewer Information | ||
| Reviewer Title | Text |
Enter the title of the person who reviewed the report.
|
| Reviewer Date Completed | Date |
Enter the date the report review was completed.
|
| Reviewer Name | Text |
Enter the full name of the person who reviewed the report, last name first, then first name, then middle initial.
|
| Reviewer Phone Number | Text |
Enter the phone number of the person who reviewed the report.
|
| Reviewer Relation to Child | Text |
Enter the relationship of the reviewer to the reported child in custody of DCS.
|
| Second Child/Individual Involved | ||
| Second Child/Individual Name | Text |
Enter the last name, first name, and middle initial of the second child or individual involved.
|
| Second Child/Individual Participant ID | Text |
Provide the participant identification number for the second child or individual, if they are in DCS custody.
|
| Second Child/Individual Date of Birth | Date |
Enter the date of birth for the second child or individual.
|
| Second Child/Individual Provider/Contractor Address | Text |
Enter the address of the provider or contractor associated with the second child or individual.
|
| Second Other Notification | ||
| Second Other Person Contacted Name | Text |
Enter the full name of the second other person contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Second Other Person Contacted Phone Number | Text |
Enter the phone number of the second other person contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Second Other Person Contacted Date | Date |
Enter the date the second other person was contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Second Other Person Contacted Time | Time |
Enter the time the second other person was contacted. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Second Witness Information | ||
| Second Witness Name | Text |
Please enter the full name of the second witness, including their last name, first name, and middle initial.
|
| Second Witness Phone Number | Text |
Please provide the phone number of the second witness.
|
| Second Witness Relationship | Text |
Please describe the relationship of the second witness to the child or children who are the subject of the report.
|
| Radiobutton |
|
|
| Radiobutton |
|
|
| Radiobutton |
|
|
| Sixth Child/Individual Involved | ||
| Sixth Child/Individual Name | Text |
Enter the last name, first name, and middle initial of the sixth child or individual involved.
|
| Sixth Child/Individual Participant ID | Text |
Enter the participant ID for the sixth child or individual, if they are in DCS custody.
|
| Sixth Child/Individual Date of Birth | Date |
Enter the date of birth for the sixth child or individual.
|
| Sixth Child/Individual Placed In Care Date | Date |
Enter the date the sixth child or individual was placed in care.
|
| Sixth Witness Information | ||
| Sixth Witness Name | Text |
Please provide the last name, first name, and middle initial of the sixth witness.
|
| Sixth Witness Phone Number | Text |
Please enter the phone number for the sixth witness.
|
| Sixth Witness Relationship | Text |
Please describe the relationship of the sixth witness to the child(ren) subject of the report.
|
| Third Child/Individual Involved | ||
| Third Child/Individual Name | Text |
Provide the full name of the third child or individual involved in the incident, including their last name, first name, and middle initial.
|
| Third Child/Individual Participant ID | Text |
Enter the participant ID for the third child or individual if they are in DCS custody.
|
| Third Child/Individual Date of Birth | Date |
Provide the date of birth for the third child or individual.
|
| Third Child/Individual Placed in Care Date | Date |
Enter the date the third child or individual was placed in care.
|
| Third Other Notification | ||
| Third Other Contact Person Name | Text |
Enter the name of the third 'Other' person contacted for verbal notification. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Third Other Contact Phone Number | Text |
Enter the phone number of the third 'Other' person contacted for verbal notification. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Third Other Contact Date | Date |
Enter the date of verbal notification for the third 'Other' contact. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Third Other Contact Time | Time |
Enter the time of verbal notification for the third 'Other' contact. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Third Witness Information | ||
| Third Witness Name | Text |
Please enter the full name of the third witness, including their last name, first name, and middle initial.
|
| Third Witness Phone Number | Text |
Please provide the phone number for the third witness.
|
| Third Witness Relationship to Child(ren) | Text |
Please describe the relationship of the third witness to the child or children who are the subject of this report.
|
| Select if No Information Found | Checkbox |
Check this box if no information was found for the police report number.
|
| DCS Specialist/Supervisor | Checkbox |
Check this box if the DCS Specialist/Supervisor was verbally notified. Fill only if 'Child in DCS Custody' is 'Yes'
Depends on:
Participant ID, Second Child/Individual Participant ID, Third Child/Individual Participant ID, Fourth Child/Individual Participant ID, Fifth Child Participant ID, Sixth Child/Individual Participant ID
|
| Licensing Agency | Checkbox |
Check this box if the Licensing Agency was verbally notified. Fill only if 'Name of Licensing Agency/Group Home/Shelter' is filled
Depends on:
Licensing Agency/Group Home/Shelter Name
|