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Run: Shelter Resident Behavioral Incident Report

Document resident rule violations, conflicts, injuries, and safety incidents in one shelter incident report. Use it to capture facts, staff response, and dir...

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Report Overview

Date of This Report (required)

The date this report is being completed (may differ from the incident date).

Time of This Report (required)

Reporting Staff Member Name (required)

Staff Title / Role (required)

If 'Other', please specify title

Shelter / Facility Name or Location (required)

Resident Information

Resident Name (Primary) (required)

Resident Case / Intake ID (required)

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? (required)

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 (required)

Time of Incident (approximate if unknown) (required)

Location of Incident (required)

If 'Other', specify location

Incident Category (select all that apply) (required)

If 'Other', describe the category

Factual Description of the Incident (required)

Include what was said or done, by whom, and in what sequence. Avoid conclusions or diagnoses.

Has this resident had prior documented incidents? (required)

Brief Summary of Prior Incidents (dates and types)

Injury, Harm, or Property Damage

Did any person sustain a physical injury? (required)

Who was injured?

Describe the injury and body part(s) affected

Medical treatment provided or sought

Was any property damaged? (required)

Describe the property damage and estimated value

Witnesses & Evidence

Were any witnesses present? (required)

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) (required)

Was law enforcement contacted? (required)

Law Enforcement Agency, Officer Name / Badge #, and Outcome

Does this incident trigger a mandatory report (e.g., child abuse, elder abuse, domestic violence)? (required)

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? (required)

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 (required)

Supporting Rationale for Recommendation

Has a supervisor or director been notified of this incident? (required)

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? (required)

Follow-Up Due Date

Follow-Up Assigned To

Reporting Staff Signature (required)

By signing, you attest that the information in this report is accurate and complete to the best of your knowledge.

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