WF: Program Incident ReportWF: Program Incident ReportIncident FormParticipant's Name(Required) First Last Program(Required)Neighbors at WorkKids ProgramsYouth ProgramsKaty's Kids PreschoolType of Incident(Required)Program RelatedMedical/SafetyHousingAbuse/ViolenceOtherLevel of Incident(Required)Level 1: GreenLevel 2: YellowLevel 3: RedDate of Incident(Required) Time of Incident(Required) Hours: Minutes AMPM AM/PMLocation of Incident(Required)Description of Incident(Required)Staff or Volunteers Involved(Required)Name and Title, including Person Filing Report if involvedOther Program Participants Involved(Required)Staff's Immediate Response:(Required) Secured and Created Safe Work Environment/Task Shared Resources Active Listening, Compassion & Empathy Helped with Regulation / Breathing Referral to Appropriate Professional Services Transported to / Assisted in Seeking Medical Care Actively Sought Emergency Resources Filed DCS Report Called 911 1 on 1 Coaching with Participant Parent Report and Coaching OtherStaff's Follow Actions to Be Taken:(Required) Change in Service/Accommodation Given One on One Session with Case Manager Family Session with Staff Other NoneImmediate Action – Other DescriptionFollow Up – Other DescriptionBackup Document Upload if NeededMax. file size: 256 MB.Name & Title of Person Filing Incident Report(Required)Email(Required) Signature of Person Filing Incident Report(Required)Your NameYour NameYour NameYour Name Navigating Crisis by media.workforce
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