Shelter Resident Behavioral Incident Report

Documents rule violations, conflicts, and safety incidents involving shelter residents. Supports staff response documentation, due process, and exit decisions for shelter directors.

Report Overview

• Date of This Report
  The date this report is being completed (may differ from the incident date).
• Time of This Report
• Reporting Staff Member Name
• Staff Title / Role
• If 'Other', please specify title
• Shelter / Facility Name or Location

Resident Information

• Resident Name (Primary)
• Resident Case / Intake ID
  Use the shelter's internal intake or case management ID number.
• Program / Unit Assigned
• Approximate Length of Current Stay
• Were additional residents involved in this incident?
• Additional Resident Name(s) and Case IDs
  Include only residents directly involved. Do not include bystanders here — use the Witnesses section.

Incident Details

• Date of Incident
• Time of Incident (approximate if unknown)
• Location of Incident
• If 'Other', specify location
• Incident Category (select all that apply)
• If 'Other', describe the category
• Factual Description of the Incident
  Include what was said or done, by whom, and in what sequence. Avoid conclusions or diagnoses.
• Has this resident had prior documented incidents?
• Brief Summary of Prior Incidents (dates and types)

Injury, Harm, or Property Damage

• Did any person sustain a physical injury?
• Who was injured?
• Describe the injury and body part(s) affected
• Medical treatment provided or sought
• Was any property damaged?
• Describe the property damage and estimated value

Witnesses & Evidence

• Were any witnesses present?
• Witness Name(s), Role, and Brief Account
  Do not include full contact details for residents. Use case IDs for resident witnesses.
• Evidence collected or available (select all that apply)
• Attach Supporting Documentation (photos, statements, etc.)
  Accepted formats: PDF, JPG, PNG. Maximum 10 MB per file.

Immediate Staff Response

• Immediate Actions Taken by Staff (select all that apply)
• Was law enforcement contacted?
• Law Enforcement Agency, Officer Name / Badge #, and Outcome
• Does this incident trigger a mandatory report (e.g., child abuse, elder abuse, domestic violence)?
  Consult your organization's mandatory reporting policy and applicable state law. When in doubt, report.
• Mandatory Report Agency and Submission Status
• Was the resident informed of the incident report and their right to respond?
  Due process requires that residents be informed of documented incidents and given an opportunity to provide their account.
• Resident's Account or Response (if provided)

Recommended Action & Director Review

• Reporting Staff Recommendation
• Supporting Rationale for Recommendation
• Has a supervisor or director been notified of this incident?
• Supervisor / Director Notified
• Director's Formal Disposition
  To be completed by the shelter director after review.
• Director Notes and Rationale
• Is follow-up action required?
• Follow-Up Due Date
• Follow-Up Assigned To
• Reporting Staff Signature
  By signing, you attest that the information in this report is accurate and complete to the best of your knowledge.