Investigation Report Information:
NJ IRMS #:	Click here
Agency/Provider Name:	Click here
Site Address:	Click here	VID/Site ID #:	Click here
Date & Time of the Alleged Incident:	Click here	Time:	Click here
Date Investigation Started:	Click here
Date Guardian Notified of Investigation:	Click here	Guardian Notified Via:	Phone	☐	Email	☐

Description of the Incident location: Setting (i.e. in dining room eating dinner, while at park, in van on Rt. 9, etc.)
Click here

Events leading up to reportable incident, please explain and describe: Activity | People | Change in Routine | Possible Trigger
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Description of the Incident: Summarize what was reported in initial incident report
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Additional Allegations: Summarize additional allegations that were discovered during the course of the investigation (if applicable)
Click here

Incident Codes:
Incident Category:	Click here
Incident Code:	Click here
Sub-Category:	Click here
Findings:	Substantiated/Yes	☐	Unsubstantiated/No	☐
* To duplicate this section for each additional victim, click here, then the plus sign to the right.

Alleged Victim(s) Information:
Full Legal Name:	Click here
Level of Supervision at the time of the incident:	Click here
Has the guardian been notified about this incident report:	Yes	☐	No	☐
* If “No” and not SKL, please write explanation below.* If “No” and SKL, please send in justification on agency letterhead.
Click here
Person Notified:
First Name:	Click here	Last Name:	Click here	Title:	Click here
Notified by:
First Name:	Click here	Last Name:	Click here	Title:	Click here
Date:	Click here	Time:	Click here
Support Coordinator Notified:	Yes	☐	No	☐
* To duplicate this section for each additional victim, click here, then the plus sign to the right.

Alleged Perpetrator(s) Information:

Full Legal Name:	Click here
Title:	Click here	Male	☐	Female	☐
AP’s Date of Birth:	Click here
* To duplicate this section for each additional witness, click here, then the plus sign to the right.

Witness/Collateral Information:
Full Legal Name:	Click here	Witness	☐	Collateral	☐
Title and/or Relationship:	Click here
* To duplicate this section for each additional witness, click here, then the plus sign to the right.

All Staff on Shift & IRS’ in Home/Location: Please list all IRS’s present and staff on shift (even if on break at time of the incident). If the incident occurred at Day Program, list IRS in the AV’s group.
Legal Name	Title / Relationship
Click here	Click here
Click here	Click here
Click here	Click here
Click here	Click here
Click here	Click here
Click here	Click here

Evidence Reviewed:
Name of Document:	Click here
Date of Document:	Click here	Date Reviewed:	Click here
Evidence Type:	Documentary	☐	Physical	☐	Video	☐
Document Review Summary: Click here
* To duplicate this section for each interview, click here, then the plus sign to the right.

Interviews:

Full Name:	Click here	Date of Interview:	Click here
Title/Relationship:	Click here
Location:	Click here
Others Present:	Click here
Person Type:	AP	☐	AV	☐	Witness	☐	Collateral	☐
Summary of Interview:
Click here
* To duplicate this section for each interview, click here, then the plus sign to the right.

All Other Contacts:

Full Name:	Click here	Date:	Click here
Title/Relationship:	Click here
Summary:
Click here
* To duplicate this section for each contact, click here, then the plus sign to the right.

Conclusion/Analysis of Evidence for Allegation and/or Event: A finding for each code is required; please ensure that findings are listed for each alleged victim and each alleged perpetrator:

Incident Category:	Click here
Incident Code:	Click here
Sub-Category:	Click here
Name of Alleged Victim(s):	Click here
Name of Alleged Perpetrator(s):	Click here
Findings:	Substantiated/Yes	☐	Unsubstantiated/No	☐
Utilize templates below:
ALLEGATION FINDINGS: Based upon a preponderance of the [testimonial/documentary/physical/video] evidence obtained, the allegation that [Mr./Ms. First and Last Name] was [abused/neglected/exploited] by [Agency/Facility name] [staff title] [Mr./Ms. First and Last Name], is [substantiated/unsubstantiated]. Specifically, on xx/xx/xx, [insert summary of findings.] Summarize specifically what the investigation determined occurred (not the initial allegation) and include whether or not what the AP did resulted in an injury to the AV. Specifically describe the injury and what treatment was required. The findings are supported by the following: Bullet out all evidence that supports the findings Include interviews, physical and documentary evidence EVENT FINDINGS: Incidents with Event only codes should be investigated to rule out abuse or neglect. Based upon the information obtained, it is [confirmed or not confirmed] that [Mr./Ms. First Last Name] experienced an [insert event]. Abuse and neglect [was/was not] determined to be a factor. The findings are supported by the following: Bullet out all evidence that supports the findings Event findings are more brief
* To duplicate this section for each finding, click here, then the plus sign to the right.

Related Concern(s): List any concerns that were identified
Summary:
Click here
* To duplicate this section for each concern, click here, then the plus sign to the right.

Actions Taken & Planned:

Immediate Actions:	Choose an item.
Completion Date:	Click here
Summary:
Click here
* To duplicate this section for each action taken/planned, click here, then the plus sign to the right.

Corrective Action:	Choose an item.
Planned Date:	Click here	Completion Date:	Click here
Summary:
Click here
* To duplicate this section for each corrective action, click here, then the plus sign to the right.

Preventative Actions:	Choose an item.
Planned Date:	Click here	Completion Date:	Click here
Summary:
Click here
* To duplicate this section for each preventative action, click here, then the plus sign to the right.

Date Investigation Completed:	Click here
Attestation: ☐ Yes ☐ No	I hereby certify that the assigned Investigator is an impartial person who was not directly involved in the incident being investigated.
Investigation Completed by:	Click here	Title:	Click here
Contact Phone number:	Click here	Email:	Click here
Date Submitted to DHS/OPIA:	Click here

The information contained in this report is confidential. This document is for internal use only and is not public document. Only those with a need to know and authority to review this report may review the report. This report may contain confidential client information, as well as protected health information, which is protected by state and federal confidentiality laws. Unauthorized disclosure of any of the contents of this report may result in civil and/or criminal penalties.