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Sample Child Safety Incident After-Action Report
| This form is intended to collect information about incidents in violation of the (Name of YSO) Policies and Procedures for child and youth safety, boundary violations, disclosures of abuse, child/youth safety concerns or other behaviors or allegations of behavior that led to the suspicion that a child/youth in our care was being or was in danger of being harmed. The information in this report will be used in the ongoing analysis of our policies, training, and responsibilities to keep our children and youth safe. As such, the children or youth that are the subject(s) of the information do not need to be identified by name. NOTE: This form is for statistical analysis only and does not substitute for an individual’s responsibility to report incidents of suspected child abuse or neglect to (Organization name) or to DCF. |
| 1. Date of incident(s)/behavior(s): |
| 2. Number of children/youth involved: |
| 3. Ages and gender of children/youth involved: |
| 4. Description of incident(s)/behavior(s): (attach additional sheets as needed) |
| 5. How did the situation come to your attention? mm Child self-disclosed mm Employee observed mm Employee suspected mm Volunteer observed mm Volunteer suspected mm Other individual disclosed,observed or suspected mm Who?: |
| 6. Who did the report/incident involve? mm Family member mm Another child/youth mm Staff member mm Volunteer mm Stranger mm Other mm Who?: |
| 7. Was the incident reported to [name of internal reporting authority]? mm Yes mm Immediately; Within 24 hours; Other mm No (please explain) |
| 8. Was phone contact with DCF made? mm Yes mm Immediately; Within 24 hours; Other mm No (please explain) |
| 9. Was a written report (51A) filed within 24 hours of the phone contact with DCF? mm Yes mm Immediately; Within 24 hours; Other mm No (please explain) |
| 10. Is there any way we at [Name of organization] can improve our response in situations like this? mm Yes mm Refresher Training; Assist with parents; More on-site technical assistance mm Other (please explain): mm No |
| 11. Is there any way we can prevent situations like this from happening in the future? |
| 12. Any other comments/observations? |
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