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The Children's Home of Kingston
26 Grove Street
Kingston, NY 12401
p: 845-331-1448
f: 845-334-9507
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Date
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Staff Name
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Dept
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Submitter Name
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Explore Staff member’s point of view; incident description:
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How was the staff feeling? Did the staff member use the four questions in a crisis recommended by TCI? (How am I feeling? How is the child feeling? How is the environment? How do I best respond?)
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Are there any supports the agency can provide to assist the staff member?
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Did the staff follow agency policy and procedure for incident reporting, calling for assistance and proper incident documentation?
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Yes
No
If No an explanation is required.
Did the staff follow ICMP or BIP?
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Yes
No
If yes, are there any recommendations for revision . If no, why was it it not completed?
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If the incident involved a restraint, did the staff notify the supervisor?
Yes
No
If the incident involved a restraint, was nursing notified?
Yes
No
Did the staff need medical attention?
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Yes
No
If so, did they notify their Supervisor?
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Yes
No
Did the staff notify HR and submit a Work Related Injury form?
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Yes
No
Reflecting on the incident is the staff able to identify any interventions or approaches that may have helped de-escalate the situation for a better outcome? Did the staff request further training?
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Were there any supports identified to assist staff member to achieve better outcomes in the future?
*
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Home
About Us
Board & Staff
History
Privacy Policy
Wellness Policy
Programs
Independent Living Skills
New Horizons
Residential Treatment
Services
Behavior Management
Educational
Health
Recreational
Admissions
News/Events
Calendar
Newsletter
Gallery
Employment
Job Openings
Benefits
Application
Contact
