CONTACT CENTER POLICIES & PROCEDURES
Incident Report Instructions
EFFECTIVE DATE:
January 25, 2013
REVISION DATE:
April 4, 2018
OVERVIEW
The MHA- NYC’s Incident Report is to be completed as per the Incident Review/Quality of Service Policy
and Procedure.
GUIDELINES FOR COUNSELORS
This form should be completed by the Counselor who handled the call and emailed to the Quality
Improvement Manager and Administrative Assistant on the same day as the incident. The incident report
form includes a mixture of drop-down and text boxes. Below is an explanation of what information needs
to be completed for each section.
Field
Program name
Incident Location
Date of Occurrence
Time of Incident
CRN
People Involved
Relationship to Program
Type of Incident
Description of the Incident
Actions Taken
Was Anyone Hurt
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Description
Enter the Line the call came in on
The address where the abuse occurred
Date the call was placed to the Call Center
Time the call was placed to Call Center
Call Report Number
Include the name of the Counselor that handled
the call. List all key people involved including
alleged abuser, victim etc. If you don’t know the
name of the key people it is not necessary to list
them. For a child abuse report, the LDSS2221a is
attached to the Incident Report so the reviewer
will be able to see that you didn’t know the names
of the key people.
This should be ‘staff’ for the Counselor and
‘consumer’ for anyone else.
This is typically ‘abuse’ for our purposes. If the
incident is not related to abuse select ‘other’.
Describe who the caller is and what they reported.
Include the relevant information regarding the
suspected abuse that documents why your
actions were necessary. Include the CRN here.
Describe the actions taken by the Counselor.
This is typically calling APS or the SCR as well as
what other interventions (referrals, EMS, MCT
etc) were provided.
Document here only if the caller described a
specific injury related to the incident.
CONTACT CENTER POLICIES & PROCEDURES
Who Was Notified
Reporter Name & Credentials
Signature
Date
Include all of the details that are relevant and that
you have knowledge of – who was hurt, what the
injury was, and the treatment provided.
This section isn’t always relevant to the call and
will sometimes be left blank.
The name of the person accepting the report (at
the Statewide Central Register or APS), the
agency name, and the date the report was
placed. Also include any shift supervisors notified
of incident.
The person completing the form/the name and
credentials of the Counselor who handled the call
Initials of the Counselor who handled the call
The date the report was completed.
Email the form to the Quality Improvement Manager and the Administrative Assistant.
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