Exhibit XX ADJC-5002 ADJC Service Providers Protocol ADJC.doc
DOC document 58 KB Posted
- Attached to
- Master Agreement AZ|CTR071466
- Contract number
- CTR071466
- Issued by
- Arizona
About this file
This document is an Incident Reporting Protocol for the Arizona Department of Child Safety (ADJC), specifically outlining service providers' responsibilities for reporting unusual or significant incidents involving juveniles under ADJC jurisdiction. The protocol applies to service providers working with ADJC juveniles, including those who are dual wards (adjudicated delinquent and dependent), and establishes comprehensive reporting procedures for both regular business hours and after-hours scenarios.
The protocol details specific incident types requiring immediate reporting, including but not limited to deaths, serious injuries, use of restraint or physical force, sexual incidents, law enforcement interactions, absences without leave, assaults, property damage, substance use, and other potentially newsworthy events. Service providers are required to make verbal reports within two hours of an incident to designated ADJC contacts and submit written reports within 24 hours, including detailed information such as juvenile identification, incident specifics, staff involvement, and follow-up actions. The protocol provides explicit communication scripts and contact information for different reporting scenarios, emphasizing timely and comprehensive incident documentation.
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Text version
EXHIBIT XX
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 twenty-four (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
DEFINITIONS
1. ADJC Juveniles:
Juveniles under the jurisdiction of ADJC and has an assigned ADJC Parole Officer.
Dual Wards: Juveniles that are adjudicated delinquent and dependent with an assigned ADJC Parole Officer and ADCS Specialist. (ADCS maybe the placing Agency).
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. Sexual assault, sexual harassment and/or allegations
4. Suicidal ideation/attempt
5. Law enforcement contact, intervention and/or arrest
6. Weapons violation
7. Absence Without Leave (AWOL)); Abscond
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
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.
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