Exhibit C ADJC Service Providers Unusual-Significant Incident Report Protocol.pdf

EXHIBIT C

State of Arizona

Department of Child Safety

Office of Procurement

3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

ADJC SERVICE PROVIDERS UNUSUAL/SIGNIFICANT

INCIDENT REPORT PROTOCOL

PURPOSE: To ensure timely notification to ADJC when incidents involving an ADJC juvenile occur(s).

SERVICE PROVIDERS RESPONSIBILITIES:

1. During *Regular Business Hours, make a verbal report to the assigned ADJC Parole Officer and the Community Services Office within 2 hours following the incident utilizing the attached Service Provider Incident Report Script.

2. During **After Hours, make a verbal report to the ADJC After Hours Administrator within two

(2) hours following the incident utilizing the attached Service Provider Incident Report Script.

3. Submit the written report of such incident(s) to the Community Services Office within 24 hours or immediately as requested by the Department via fax to 602-542-4108 or email communityservice@azdjc.gov

Written reports shall include, but not limited to the following information:

a. Name of the Service Provider and physical location

b. Juveniles name and ADJC K number

c. Date, time and location of the incident(s)

d. ADJC Parole Officer’s name

e. A detailed description of the incident to include, but not limited to environmental factors, triggers, resolution and necessary follow-up

f. Name and signature of the Service Provider staff that generated the report

g. Date, time and name of the ADJC staff that the initial notification was made to or if a voice message was required

h. Any additional information as requested by the Department

4. Provide additional information for the following incidents:

a. Use of restraint or force

i. Type of counseling or verbal redirection used

ii. Type of restraint device or hold

iii. Length of time the juvenile was restrained or held

iv. Injuries that may have been sustained and follow-up medical attention

b. Allegations of criminal activity requiring notification to law enforcement

i. Law enforcement agency

ii. Law enforcement report number

iii. Responding Officer’s name mailto:communityservice@azdjc.gov

Department of Child Safety

Office of Procurement

3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

DEFINITIONS

1. ADJC Juvenile:

Juveniles under the jurisdiction of ADJC and receiving services funded by ADJC, DCS, T/RBHA, Inter-state or Private pay.

2. *Regular business hours/contact:

a. 8:00 AM - 5:00 PM Monday - Friday

b. Community Services Office: 602-542-4157

3. **After Hours/contact:

a. 5:01 PM - 7:59 AM Monday through Friday

b. All hours Saturday’s, Sunday’s and all Holidays

c. ADJC After Hours Administrator: 602-526-6063

4. Incident:

Any event affecting safety, programmatic, or contractual impact including, but not limited to:

1. Death of a juvenile and/or serious injury requiring outside medical and or behavioral health intervention.

2. Service Provider’s use of restraint or physical force

3. Allegations of physical or sexual abuse

4. Suicidal ideation/attempt

5. Law enforcement contact, intervention and/or arrest

6. Weapons violation

7. Absence Without Leave (AWOL)

8. Assault, fighting, or physical aggression

9. Property damage (if a Police report is filed)

10. Theft (if a Police report is filed)

11. Substance use

12. Adverse reactions to medications resulting in medical intervention

13. Emergency evacuation

14. Physical plant disasters

15. Any event involving juvenile, service provider staff, or the community, that may be newsworthy or politically sensitive

16. Transportation/traffic related

17. Other criminal or unusual behavior

Department of Child Safety

Office of Procurement

3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

SERVICE PROVIDER INCIDENT REPORT SCRIPT

During regular business hours, contact the assigned Parole Officer and the Community Services Office at 602-542-4157. For After Hour’s notification, contact the After Hours Administrator at 602-526-6063. In your notification, please include the following information:

1. This is (caller’s name)

2. From (Service Provider)

3. Located at (site location)

4. Juvenile’s name

5. K number

6. Parole Officer

7. Incident description

8. Date of incident

9. Time of incident

10. Service Provider/Caller’s call back number

The initial phone notification should be brief. The subsequent incident report should be comprehensive and shall be faxed or emailed to the ADJC Community Services Office at 602-542-4108 or communityservice@azdjc.gov within 24 hours or immediately as requested by the Department.

mailto:communityservice@azdjc.gov