DYCD Incident Form – Fill Out and Use This PDF

DYCD human service providers (“Providers”) are contractually obligated to report program-related injuries and occurrences (“Incidents”) to DYCD. This Policy explains which Incidents must be reported to DYCD and how

and when Incident reporting must occur.

Notice & Reporting

1.24-Hour Notice: Providers must notify DYCD of an Incident within 24 hours by telephone or e-mail.

a.Notifying DYCD should never delay or otherwise interfere with responding to Incidents. Emergency actions, such as calling for an ambulance, should always take precedence.

b.Such initial notification may be satisfied by submitting a completed DYCD Incident Report Form.

2.3-Day Report: Providers must submit a completed DYCD Incident Report Form by e-mail within three days of an Incident to both of the following:

a.DYCD Program Manager (overseeing the contract to which the Incident relates), and

b.incidentreports@dycd.nyc.gov

3.CIP: Providers enrolled in the City's Central Insurance Program must also email the completed Incident Report Form to cip@dycd.nyc.gov.

a.Providers should review insurance policies to determine whether it is necessary to report the Incident to their insurance carrier.

Incidents to Report

1.Providers must report to DYCD any Incident which potentially impacts the health, safety, or well-being of an individual, property, or the operation of a DYCD-funded program and any Incident which stems from or is otherwise related to DYCD-funded programming.

2.Examples of Incidents that must be reported include the following:

a.Bodily injury (e.g. a broken ankle, torn ACL, or serious laceration), threats to an individual’s well- being, self-abusive behavior, property damage, shootings, and fires;

b.Child abuse (actual and suspected), including Incidents that may be sexual in nature, and occurrences involving inappropriate personal boundaries, communications, touching, and photos;

c.Incidents where Emergency Medical Services or Police are called, or which may be of media interest;

d.Lapses in the supervision of school-aged children; and

e.Any other Incident which falls into the definition of Incidents in Section 1; this list of examples is meant to illustrate common types of Incidents, not to serve as a comprehensive list.

3.Minor occurrences need not be reported; for example, Incidents typical of childhood or otherwise minor (e.g. a scraped knee from a fall, an isolated and non-serious verbal altercation) need not be reported to DYCD.

Incident Guidance

1.SCR: In cases of actual or suspected child abuse or maltreatment by a parent or person legally responsible for

a child, Providers must report such Incidents to the New York Statewide Central Register of Child Abuse and Maltreatment (“SCR”). Reporting to the SCR should always take precedence over reporting to DYCD.

2.Records: Providers must maintain a record of all Incident Reports and a record of actions taken to address Incidents. Such records are subject to DYCD review and audit.

3.Report Requests: When determining whether to share a completed DYCD Incident Report with a participant’s parents or representatives, Providers are encouraged to consult with DYCD.

4.Press Inquiries: Providers should notify DYCD of any media inquiries related to an Incident. Providers are encouraged to coordinate with DYCD in responding to such inquiries.

5.Incident Resolution: Providers should work with DYCD in addressing and resolving Incidents. However, it is ultimately Providers’ responsibility to resolve Incidents.

Revised June 2016