Exhibit CSO-1151A.pdf

CSO-1151A

(07/25)

Incident Report for Children in the Custody and Care of the Arizona Department Of Child Safety (DCS)

Confidential Information

Describe Event or Incident Yes, Additional Pages Attached

To be Completed by Responsible Person(s) Involved In/Witnessing the Incident

Include in detail what happened prior to, during, and after the incident. As applicable, include details of the child’s mental and physical condition before, during, and after the incident. If any injuries occurred, describe the appearance and location of the injuries.

Name Of Child/Individual Involved (Last, First, M.I.)

Participant ID (If in DCS Custody)

Date of Birth (mm/dd/yy)

Placed In Care Provider/Contractor Address

Name of Licensing Agency/Group Home/Shelter (If Applicable) Group Home Facility/Cottage/CasitaName of Out-Of-Home Care Provider

Name of Contracted Agency

Location Of Incident (No., Street) City

Date Of Incident

State

Time Of Incident

Zip

QCID

Incident Report for Children in the Custody and Care of DCS ~ Confidential Information

Witnesses Yes, Additional Pages Attached

Name of Witness (Last, First, M.I.) Witness Phone Number Relationship Of Witness To Child(ren) Subject Of Report

No N/AYesIf the Incident Involved Allegations of Child Abuse/Neglect, was the Child Abuse Hotline Notified?

Child Abuse Hotline Notification

Time Name Of DCS Intake Specialist

Notifications

Date

For questions, reporting requirements, and submittal of this Incident Report refer to the following:

• Unlicensed out-of-home care provider: Contact the DCS Specialist/ Supervisor for any questions and/or reporting requirements.

Send a copy of this Incident Report to the DCS Specialist/Supervisor.

• Licensed foster homes: Contact your Child Placing Agency, DCS Specialist/Supervisor, or the Office of Licensing and Regulation (OLR) for questions and/or reporting requirements. Send a copy of this Incident Report to your Child Placing Agency, DCS Specialist/ Supervisor, and OLR (email to: olrincidentreportsfh@azdcs.gov).

• Shelters/Group Homes: Contact your DCS Specialist/Supervisor, Office of Licensing and Regulation (OLR) and/or DCS Contracts for any questions and/or reporting requirements.

• Send a copy of this Incident Report to your DCS Specialist/ Supervisor; OLR (email to: olrincidentreportscwl@azdcs.gov); and DCS Contracts (email to: contracts@azdcs.gov).

• Shelters/Group Homes (Non-DCS Contracted): Contact the Office of Licensing and Regulation (OLR) for any questions on reporting requirements. Send a copy of this incident report to OLR (email to:

olrnoncontractedincidentreports@AZDCS.gov).

• Contracted Service Provider: Contact the DCS Specialist/Supervisor for any questions and/or reporting requirements. Send a copy of this Incident Report to the DCS Specialist/Supervisor and DCS Contracts email Contracts@azdcs.gov (please be sure to reference contract).

Describe Steps Taken to Prevent Incident at the Time of Incident and in the Future

Explain any actions taken prior to the incident to prevent it. For example, was the RBHA, Probation, DCS Specialist, or DDD engaged prior to incident?

What actions were taken after the incident to prevent the incident from occurring again?

Yes, Additional Pages Attached mailto:olrincidentreportsfh%40azdcs.gov?subject= mailto:olrincidentreportscwl@azdcs.gov mailto:contracts@azdcs.gov mailto:olrnoncontractedincidentreports%40AZDCS.gov?subject= mailto:Contracts%40azdcs.gov?subject=

Incident Report for Children in the Custody and Care of DCS ~ Confidential Information

DCS Specialist/ Supervisor

DCS Contracts OLR/OLCR Licensing Agency

Juvenile Probation

Other

Date: Date: Date: Date: Date: Date:

Signature/Title of Person who Prepared this Report

Signature/Title of Person who Reviewed this Report (If Applicable)

Copy Of Written Report Sent To: (Include the Date Sent)

Title

Title

Signature

Signature

Name (Last, First, M.I.)

Name (Last, First, M.I.)

Phone No.

Phone No.

Relation To Reported Child In Custody Of DCS

Relation To Reported Child In Custody Of DCS

Date Completed:

Date Completed:

No N/AYesWas Law Enforcement Notified?

Law Enforcement

Based on incident description, check which contacts were verbally notified

Officer Badge Number Police Report NumberName Of OfficerName of Law Enforcement Agency

Record of Verbal Notification Select if No Information Found

Check Contacts Notified Name Of Person(S) Contacted Phone Number Date Time

DCS Specialist/Supervisor

Licensing Agency

Juvenile Probation/Parole

Contracted Service Provider

Other

Other

Other

Incident Report for Children in the Custody and Care of DCS ~ Confidential Information

General Instructions For Completion

1. Enter the name of the Out-of-Home Care Provider.

2. Enter the name of the licensing agency/group home/shelter, if applicable.

3. Enter the month, day, and year the incident or injury took place.

4. Enter the time the incident or injury occurred.

5. Enter the address of location where the incident or injury occurred.

6. Enter the last name, first name, and middle initial of each child involved in the incident or injury, regardless of whether the child is in DCS custody. If child is not in DCS custody, complete as fully as possible.

7. If the child is in DCS custody, enter the child's Participant ID.

8. Enter the birth date for each child involved in the incident or injury.

9. Enter the name of the child's out-of-home caregiver or contracted placement and his/her addpress.

10. Describe the event, incident, and/or injury in detail. Give a statement of facts leading up to the event and after the event.

Indicate the child's physical and mental status before, during and after the event.

11. Document any preventative actions you may have taken prior to the event, incident, and/or injury. Describe what steps will be taken to prevent the event, incident, and/or injury from occurring in the future.

12. Enter the last name, first name, and middle initial of each witness.

13. Enter the telephone number of each witness.

14. Indicate the relationship of the witness to the child.

15. Indicate if the Child Abuse Hotline was notified. Incidents of child abuse and neglect must be reported as outlined in Arizona Revised Statutes § 13-3620.

16. If applicable, indicate if law enforcement was notified. If so, enter the name of the officer, the officer's badge number, and the law enforcement report number.

17. Indicate who was verbally notified of the event, incident, and/ or injury. Enter the name of each person contacted, the date and time reported, and the contacted person's phone number.

18. Enter the last name, first name, and middle initial of the person who prepared the report. Include the person's phone number, title, and relation to the child or children involved in the event, incident, and/or injury. Sign and date the report.

19. All relevant information and documentation should be reviewed.

Enter the last name, first name, and middle initial of the person who reviewed the report. Include the person's phone number, title, and relation to the child or children involved in the event, incident, and/or injury. Sign and date the report.

20. Indicate to whom written copies of the report were sent.

If needed, indicate additional informed parties under Other.

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to allow a person with a disability to take part in a program, service, or activity are available upon request. To request this document in alternative format or for further information about this policy contact your local office. TTY/TDD Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DCS esta disponible a solicitud del cliente.