Exhibit G CSO-1151A Significant Incident Report.docx

CSO-1151A (5-17)

ARIZONA DEPARTMENT OF CHILD SAFETY

INCIDENT REPORT FOR CHILDREN IN THE CUSTODY AND CARE

OF THE ARIZONA DEPARTMENT OF CHILD SAFETY (DCS)

TO BE COMPLETED BY RESPONSIBLE PERSON(S) INVOLVED IN/WITNESSSING THE INCIDENT

1. NAME OF OUT-OF-HOME CARE PROVIDER

2. NAME OF LICENSING AGENCY/GROUP HOME/SHELTER (If Applicable)

3. DATE OF INCIDENT (MM/DD/YY)

4. TIME OF INCIDENT

5. LOCATION OF INCIDENT (NO., STREET, CITY, STATE, ZIP)

(If in DCS Custody)

10. DESCRIBE EVENT OR 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.)

11. 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?)

CSO-1151A (5-17) – PAGE 2

15. IF THE INCIDENT INVOLVED ALLEGATIONS OF CHILD ABUSE/NEGLECT, WAS THE CHILD ABUSE HOTLINE NOTIFIED?

TIME

NAME OF DCS INTAKE SPECIALIST

NOTIFICATIONS

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 ).

16. WAS LAW ENFORCEMENT NOTIFIED?

|_| YES

|_| NO

NAME OF OFFICER AND BADGE NUMBER

POLICE REPORT NUMBER

18. SIGNATURE/TITLE OF PERSON WHO PREPARED THIS REPORT

SIGNATURE

TITLE

DATE

NAME (Last, First, M.I.)

PHONE NUMBER

RELATION TO REPORTED CHILD IN CUSTODY OF DCS

19. SIGNATURE / TITLE OF PERSON WHO REVIEWED THIS REPORT (If Applicable)

SIGNATURE

TITLE

DATE

NAME (Last, First, M.I.)

PHONE NUMBER

RELATION TO CHILD/REN SUBJECT OF REPORT

20. COPY OF WRITTEN REPORT SENT TO (Include the date sent):

DATE:

DATE:

DATE:

DATE:

CSO-1151A (5-17-draft) – PAGE 3

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 address.

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 • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. 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 Department services is available upon request. • Disponible en español en la oficina local.