DYCD Incident Form PDF Details

In the realm of human services, the importance of prompt and effective incident reporting cannot be overstated, serving as a crucial component of program management and oversight. The Department of Youth and Community Development (DYCD) Incident Report Form epitomizes this critical process, laying out a clear and structured protocol for contracted service providers to report incidents that occur within DYCD-funded programs. Providers are mandated to notify the DYCD of any incidents within 24 hours via telephone or email, and subsequently, a detailed report must be submitted within three days. This procedure ensures a swift response to situations that may impact the health, safety, or well-being of participants, staff, or the operation of the program itself. Incidents requiring reporting range from injuries and threats to welfare, to suspicions of child abuse and property damage. Moreover, the form specifies additional steps such as notification to insurance carriers for those in the City’s Central Insurance Program and outlines the importance of maintaining records for review and audit. Instructions for handling follow-up actions, medical treatments, and notifications made to external bodies and individuals involved underline the comprehensive nature of the incident reporting policy. Through this structured approach, the DYCD aims to foster a safe and responsive environment within its funded programs, emphasizing the importance of transparency, accountability, and the well-being of all stakeholders involved.

QuestionAnswer
Form Name DYCD Incident Form
Form Length 3 pages
Fillable? Yes
Fillable fields 34
Avg. time to fill out 8 min
Other names DYCD application form 2020, DYCD reporting form, DYCD online forms, DYCD form

Form Preview Example

INSTRUCTIONS

1.Timeline: DYCD Providers must notify DYCD of Incidents within twenty four (24) hours of occurrence and must submit a completed DYCD Incident Report Form via e-mail within three (3) days of occurrence to both of the following:

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

b.incidentreports@dycd.nyc.gov

2.Notice to Insurance Carrier:

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

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

3.Missing information must be provided in writing as soon as it becomes available.

4.Attach additional pages if extra space is needed or to provide additional relevant information.

5.Please review DYCD’s Incident Reporting Policy for further incident reporting requirements.

Person Completing Incident Report

Name:

Title:

 

Provider/Contractor Name:

Date:

 

Contact Person for Incident Follow Up

Name:

Work Phone:

Title:

Work Email:

 

DYCD Program Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program Area (SYEP, COMPASS, etc.):

 

 

 

 

DYCD Contract ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Incident: Injury

Abuse/Maltreatment

Lost/Missing Child

Other:

 

 

 

 

Date of Incident:

 

Time of Incident:

 

 

Occurred During Program Hours? Yes

No

 

 

Incident Site Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

If Incident at a DOE Site, School Name and District & School Number:

 

 

 

 

 

Name (of Person injured, abused, etc.):

 

 

 

 

Age:

Gender:

 

 

 

Role (of Person injured, abused, etc.): Client/Participant

Guest

Staff

Other:

 

 

 

 

Parent/Guardian Name (if a minor):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Persons Involved (indicate Role: P= participant/client

T=transgressor G=guest

S=staff W=witness)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person

Age

Role

Nature of Involvement

Revised June 2016

Incident Description (Describe the incident in detail; continue on separate page if necessary)

Follow-up Actions (e.g. assistance, investigation, or policy review; if applicable, include whether any participants were expelled, suspended, or transferred; continue on separate page if necessary)

Medical Treatment Received by Injured Person (if applicable):

Participant Returned to Program: Yes

No

N/A

If Yes, Date of Return:

Notifications Made (indicate any that apply)

 

Responder

 

Date

 

Time

Responder Name

Shield

 

 

-or-

 

 

-or-

-or-

Comments

 

 

Called

 

Called

 

Investigator

 

 

Person Taking Report

ID #

 

 

 

 

 

 

 

 

 

NYPD

 

 

 

 

 

 

 

 

 

EMS

 

 

 

 

 

 

 

 

 

FDNY

 

 

 

 

 

 

 

 

 

NYC ACS

 

 

 

 

 

 

 

 

 

NYS SCR (800) 635-1522

 

 

 

 

 

 

 

 

 

NYS Justice Center

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Notified: Yes

 

No

N/A

If Yes, Date & Time Notified:

 

 

Principal Notified (DOE sites only):

Yes

No

If No, Why Not?

 

 

 

 

 

 

 

 

 

 

 

 

Property was: Lost Damaged Stolen (if applicable)

Brief Description of Property

Serial Number

Value

Revised June 2016

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

How to Edit DYCD Incident Form Online for Free

Accurate and timely completion of this form is essential for participants' safety and compliance with reporting requirements. Here is a step-by-step guide on how to fill out the DYCD Incident Report Form.

1. Gather Incident Details

Before filling out the form, collect all relevant details about the incident. This includes the incident's date, time, location, names and roles of individuals involved, and a description of what occurred.

2. Complete the Contact Information Section

Fill in the name, title, and contact details of the person completing the report. Also, include the name and contact information of a designated follow-up contact.

dycd form pdf completion process detailed (step 1)

3. Enter DYCD Program Information

Specify the program area under which the incident occurred, such as SYEP, COMPASS, etc., and include the DYCD Contract ID number. It helps categorize the incident within the specific context of the relevant DYCD-funded program.

4. Describe the Incident

In the incident description section, provide a detailed account of the incident. Include the type of incident (e.g., Injury, Abuse/Maltreatment, Lost/Missing Child), specific details of what happened, and any immediate actions taken following the incident. If more space is needed, attach additional pages.

Filling out segment 2 in dycd form pdf

5. Document Follow-Up Actions

Detail any follow-up actions taken or planned in response to the incident, such as medical treatment provided, any investigations launched, policy changes, or disciplinary actions.

How one can fill out dycd form pdf part 3

6. Record Notifications and Responses

List any notifications to emergency services, other agencies, or individuals such as parents or guardians. Include details like the name of the responder or investigator, the time and date calls were made, and any other relevant comments.

Comments, Person Taking Report, and Medical Treatment Received by inside dycd form pdf

7. Report Property Damage (If Applicable)

If the incident involved lost, damaged, or stolen property, describe the property along with any serial numbers and the estimated value.

dycd form pdf conclusion process described (part 5)

8. Review and Submit

Double-check the completed form for accuracy and completeness. Any missing information should be provided as soon as it becomes available.

Please email the completed form to the DYCD Program Manager and the designated incident report email address within the required timelines, as specified in the instructions.