POIETO INC — Incident Report Form

A — Incident Information

Date of Incident

Time of Incident

Location (building, room, address)

Date of This Report

Time of This Report

Reported to (Designated Investigator name)

B — Person Affected

Do not record participant names on forms that leave POIETO's secure files. Use initials + last 4 of participant ID, or staff file number. If law enforcement or DCFS is involved, follow their documentation requirements separately.

Participant ID / Initials

Age

Gender (if known/relevant)

Role at time of incident

Program participant Staff / TA Volunteer Other: ___________

C — Person Alleged to Have Committed the Incident (if applicable)

Name or ID

Role at POIETO

Relationship to person affected

Still on site?

Yes No

Removed from participant contact?

Yes No — reason:

D — Description of Incident

Write what you directly observed or heard, in plain language. Do not interpret, speculate, or editorialize. Use exact words where possible. If this is a disclosure, use the person's own words in quotes.

Description — what happened, in sequence, as observed or reported

E — Witnesses

Witness 1 — Name / ID

Role

Contact

Witness 2 — Name / ID

Role

Contact

F — Immediate Actions Taken

DCFS Report # (if applicable)

Law Enforcement Report # (if applicable)

Time DCFS / LE was notified

Additional actions taken or notes

G — Person Completing This Report

Full Name (printed)

Title / Role

Signature

Date & Time Submitted

H — Designated Investigator Receipt (complete upon receiving form)

Investigator Name

Date & Time Received

Signature

Assigned Case #

Investigator notes — immediate assessment and next steps