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Heart of Florida Youth Ranch IR/ER Form
Heart of Florida Youth Ranch IR/ER
Section 1: Identifying Information
Today’s Date (mm/dd/yy):
Name of Provider:
Program Name:
Date of Occurrence (mm/dd/yy):
Time of Occurrence (include am/pm):
County Completing Report:
Name of Location Where the Occurrence Happened:
Address:
City:
State:
Writer Information
Writer Name (electronic signature):
Writer Title:
Writer Phone #:
Focus Child/Person
Focus Child/Person Full Name:
Date of Birth (mm/dd/yyyy):
Race:
AA/Black
Alaskan Native
Am Indian
Asian
Hispanic
Pacific Islander
Unsure
White
Involvement:
Name of Current Placement:
Placement Type:
Placement Address:
City:
State:
Section 2: Incident or Event
Select Report Type:
Incident Report
Event Report
Incident Type:
Adult Death (parent, caregiver, staff)
Child Arrest
Child on Child Sex Abuse
Employee Arrest
Employee Misconduct
Missing Child
Child Hospital - Overnight
Other (specify)
Suicide Attempt with a Baker Act
Security Incident - Unintentional
Sex Abuse/Sex Battery
Significant Client Injury
Significant Staff Injury
Suicide Attempt-Only (No Baker Act)
Event Type:
Abuse Report Against CMA
Abuse Report Against Diversion
Abuse Report Against Foster Home
Abuse Report Against Group Home
Abuse Report Against KCI/Program
Abuse Report-Child 0-5 Domestic Violence
Abuse Report-Child 0-5 Mental Health
Abuse Report-Child 0-5 Substance Abuse
Baker Act (non-suicidal)
Child/Employee Physical Restraint
Child Illness-HOSPITAL (no well check)
Failure to Thrive
Illegal Substances-No Arrest
Minor Injury
New Baby Born into Open Case
Other: Medication Issues
Other (specify)
Serious Altercation-No Arrest
Serious Theft/Destruction-No Arrest
Section 3: Other Participants/Witnesses
List of Victim/Person involved, Witnesses, Participants, and/or Perpetrators:
Section 4: Description of Incident or Event
When (include date, time of day, etc.):
Who (be clear on who did what):
What (be detailed, e.g., actions taken):
Where (location details):
How (methods used):
Why (reasons or triggers):
Section 5: Case Management Notification
Child’s Case Manager Name:
Agency:
Date Notified:
Time Notified:
How Notified:
Section 6: Other Notifications
Parent/Guardian Name:
Date Notified (Parent/Guardian):
Time Notified (Parent/Guardian):
Relationship:
How Notified (phone, email, etc.):
Section 7: Management Review & Approval
Manager/Supervisor Name:
Manager/Supervisor Title:
Date of Review:
CMA Unit # (if applicable):
County:
Check One - Initial or Final Report:
Initial
Final
If this report is being submitted late, provide an explanation:
Exhibit B: Incident/Event Reporting Details
Please provide a detailed description of the incident/event:
Abuse Report Number (if applicable):
Intake Date:
Status:
Allegation Narrative:
Exhibit D: Kids Central Inc. Quality/Risk Management Review
Name of QM Staff Reviewing this Report:
Select One:
Incident
Event
Date Report Received:
Routed Internally (check all that apply):
KCI Legal
Training
Contracts
Report Submitted Timely?
Documented in FSFN Timely?
Form Accurately & Fully Completed?
Entered into IRAS Timely if Applicable?
Immediate or Follow-Up Actions Documented?
Returned for Corrections? (Include Dates):
Other Comments (Type of Corrections, Quality Issues, Etc.):