Reportable Event

Home Reportable Event

Resident Name *

Date of Event *

Time Began *

Time Ended *

Staff Entering Report *

Staff Phone Number *

Other Staff Involved or Witnessed (working in the home) *

Did you inform the guardian *

Yes
No
No Guardian

Guardian Name *

Guardian Phone: *

Did you inform DS Crisis *

Yes
No

Who at DS Crisis did you talk to? *

Did you inform CCC On Call *

Yes
No

Who at CCC did you inform? *

What happened before? *

Description of Event *

What happened after? *

Event Categories (Select each that apply) *

Dangerous Situation
Medication Refusal
Medication Error - Missing Med
Medication Error - Other
Verbal Aggression, Threats to Harm Others
Physical Aggression Towards Others
Property Damage
Emergency Restraint
Call to 911
Law Enforcement/Police Involvement
ER or Urgent Care Visit
Elopement/Ran Away
Verbal Threat To Harm Self
Physical Attempt To Harm Self
Rights Violation

Medication Involved *

Who were they aggressive towards? *

Emergency Restraint Type *

Single
Multiple

Time Began *

Date

Time

Time Ended *

Date

Time

Name of Staff Involved *

Duration of each Restraint *

Sitting or Standing *

Which hospital? *

Who transported? *

New Medications prescribed *

Guardian consent for medications prescribed? *

How long were they gone for? *

Did staff lose sight of resident? *

Email *

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At Coastal Community Care, we are committed to serve with care and integrity.

Coastal Community Care LLC provides residential services Androscoggin county. Our 21 waiver/ group homes provide staff support to adults with intellectual and developmental disabilities from ages 18 to 95. Typically, two individuals reside in one home, with shift staff providing support round the clock..

Contact Info

Coastal Community Care LLC
95 MAIN STREET SUITE 2B AUBURN, ME 04210
207-241-0424
info@ccchomes.org
ccchomes.org