Incident Report Date of Incident(Required) MM slash DD slash YYYY Approximate Time of Incident(Required) Hours : Minutes AM PM AM/PM Reporting Staff Member(Required)Brenda AguilarToniya AlexanderIsaura AnguloBismark AnnorMargaret Arnold-RowellsVanessa BejaranoRachel BenallyShannon BentleyKavita BernsteinDavid BlincoeCeleste BurruelBlanca CalderonKarla ChaseTrish ChristieMarilou ClelandIsamar CoronadoMarisol CurtisJacqueline DiazLyndsay DiCamilloSheri DollinSusana DoughertyLou DurantTabitha FisherJulie FitzgeraldJorge FloresDanielle FredericksBianey GarciaJennifer GarciaBeth GiacaloneNorma GopherSuzi GraberKelly GrandaCarmen GuerreroMonica GuerreroCharmekque HarbertCarolina HernandezSara HillJennifer HilsabeckNicole HolstDevin HowardJoanna JonesStephanie KaftonKatie KiceyMarinee LarranagaAmy LayneAlicia LemusAshleigh LeonardRonna LevyPaige LoefflerKatrina LopezJessica MarinDiana MartinezJini MaxwellKerrie MayneCharlotte McCarthyJaad McElroyGloria McGintyMichelle McKinleySandra MendozaJoana MirandaJannette MoralesAna MoranCatherine MulleneauxLiz MurrayJahaira MyersEmma NichiteanKatey NicosiaPatricia NordahlNatalia Ordenes RojasMichelle PahlLee PalmerBrenda Palos-CasillasLucy PapasOlivia PenaTijana PercRob PodlogarKesha PoliteMona QafishehLinda RappsRuth RayTiffany RicklefsCarla RomeroOmar SaifAmanda SanchezGabriela SanchezBianca SantosCourtney SavageLaTishay SmithBrooke StringhamAngela TapiaKira ThomasCalvina TsosiePamela UehlingAdriana ValdezIdely ValenzuelaAmy VanderJackCerissa VegaMarco VillalpandoJaki WhiteAmy WilliamsWhat type of incident was this?(Required)Suspected Abuse or NeglectAccidental injury without another party involvedInjury with another party involvedMedical emergencyObservation of altercation between adultsMissing or lost childCyber SecurityOuch ReportName(s) of the Injured/Affected Party(Required) The injured/affected party is a(n)(Required)Candelen staff memberCandelen volunteerMinor childAdultPlease enter any the parent/guardian(s) name(s) and contact information (if known)(Required)Who was notified?(Required) Arizona DCS (Department of Child Safety) Nevada DCFS (Department of Child & Family Services) Tribal Authority Arizona APS (Adult Protective Services) Nevada APS (Adult Protective Services) Local Police Department Please enter information about notification to local authorities. Who did you speak with? Badge number? Report number? What was disclosed?(Required)Enter information about anyone who witnessed the incident. Include names, company, contact information, and job title when available.(Required)Describe the injury including size, location on the body, and color in detail. If this incident did not involve bodily injury, please enter detailed information about the suspected abuse or neglect.(Required)What was the origin of the data breach?EmailSMS (Text Message)PhoneSharePointDescribe how the injury/incident occurred in as much detail as possible(Required)When the incident occurred or directly after the incident occurred, please indicate if any of the following were true(Required) No actions were taken A calm and quite place was provided for the injured/affected party First aid was provided Medical attention was provided on site by a medical professional 911 was called The parent/guardian was called and advised to seek medical treatment The parent/guardian was called and informed of the injury The parent/guardian was informed in writing within 24 hours of the incident The parent/guardian OR victim was informed that a formal report is being made to the local authorities A report was made to local authorities but the parent/guardian or victim was NOT notified What did you do when the "ouch" occurred? Provided an ice pack Provided a band-aid Cleaned the affected area How was the child's parent/guardian notified? Ouch report provided to parent/guardian at pick up Ouch report provided to authorized party picking the child up from care Parent/guardian was called Who provided first aid/medical attention?(Required) Did they seek medical treatment?(Required)YesNoUnknownWere they hospitalized?(Required)YesNoUnknownWhere did the incident/injury occur?(Required)Candelen OfficeFSE Partner LocationTraining LocationCommunity EventQF Coaching SiteEPK ClassroomParticipant's HomeOtherWhere did it occur?(Required) Location Name Address of Incident (if known) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Location Contact Person Name and Contact Information (if known) How do you think we can prevent this from happening again?(Required)