In the world of juvenile justice within Texas, the importance of accurately and promptly reporting incidents involving abuse, neglect, exploitation, or death cannot be overstated. The TJPC-ANE-05-05 form, issued by the Texas Juvenile Probation Commission (TJPC), serves as a pivotal tool in this process, ensuring that all relevant details of such unfortunate events are systematically captured and conveyed to the appropriate authorities. This comprehensive document, which must be filled out with care by involved personnel, requests information on multiple fronts: from the specifics of the incident, including the who, what, when, where, and why, to the nature of any abuse or neglect, and even the procedural follow-up with law enforcement. It mandates the reporting party to include detailed descriptions, whether the incident involved physical or emotional abuse, neglect in various forms, or even resulted in death. Furthermore, it delineates the reporting timeline, demanding certain actions within stringent time frames to facilitate swift and effective responses. The TJPC-ANE-05-05 form stands as a testament to the commitment of Texas's juvenile justice system to uphold transparency, accountability, and the welfare of the youth under its supervision.
| Question | Answer |
|---|---|
| Form Name | Form Tjpc Ane 05 05 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | TJPC-ANE-05-05, TYC, JJAEP, tjpc |
TEXAS JUVENILE PROBATION COMMISSION
INCIDENT REPORT FORM
Please complete BOTH sides and fax or
Texas Juvenile Probation Commission, ANE Investigation Unit, at (512)
OR abuseneglect@tjpc.state.tx.us
If you have any questions, please contact the Commission at (512)
Form Completed By: |
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County Case ID#: |
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1ST Person of Knowledge: |
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Date of Incident: |
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Time of Incident: |
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Was the incident originally reported using the Commission’s |
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No |
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LAW ENFORCEMENT INFORMATION
Law Enforcement Agency:
Person Notified:
Date Notified: |
Time Notified: |
Incident Number:
Phone: ( |
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Fax: ( |
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ABUSE, NEGLECT, EXPLOITATION OR DEATH
(Check all that apply)
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REPORT TO THE COMMISSION & LAW ENFORCEMENT WITHIN |
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REPORT TO THE COMMISSION WITHIN 4 HOURS & TO LAW |
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24 HOURS |
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ENFORCEMENT WITHIN 1 HOUR |
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Emotional Abuse |
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Death |
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Suicide |
Non- Suicide |
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Verbal Abuse |
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Sexual Abuse |
Contact |
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Physical Abuse: |
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Restraint Related? |
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Serious Physical Abuse: |
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If yes, what type? |
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Physical |
Chemical |
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Restraint Related? |
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If yes, what type? |
Mechanical |
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Chemical |
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Neglect Medical |
Supervisory |
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Exploitation |
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SERIOUS INCIDENTS |
– Report Within 24 Hours |
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(Check all that apply) |
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Attempted Suicide: |
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Youth on Youth Physical Assault |
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Referred for Mental Health Services? |
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Escape |
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Youth Sexual Conduct |
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Reportable Injury: Restraint Related? |
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No |
If yes, what type? |
Mechanical |
Physical |
Chemical |
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LOCATION OF INCIDENT
(specify ONLY the location in which the incident is alleged to have occurred)
Department/Program/Facility:
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Administrator: |
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Address: |
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Fax: ( |
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Probation |
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JJAEP |
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Day Reporting Program |
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ALLEGED VICTIM/JUVENILE INFORMATION |
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(A separate form must be completed for EACH alleged victim/juvenile) |
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Name: |
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Age: |
DOB: |
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Gender: |
Race: |
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PID: |
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Placing County: |
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Height: |
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Weight: |
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Is juvenile a TYC youth? |
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No |
TYC #: |
Current Location of Juvenile: |
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Facility |
Residence |
Other (specify location) |
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Name of Parent/Guardian: |
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Date Notified: |
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Time Notified: |
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Address (City, State & Zip Code): |
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Phone: |
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4900 N. Lamar Blvd., 5th Floor East |
http://www.tjpc.state.tx.us |
Phone (512) |
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Post Office Box 13547 |
Page 1 of 2 |
TDD (512) |
|
Austin, TX 78711 |
Revised 4/2010 |
Fax (512) |
ALLEGED PERPETRATOR(S)/SUBJECT(S) OF INVESTIGATION/STAFF INFORMATION
Name:
Name:
Name:
Name:
Title:
Title:
Title:
Title:
DOB:
DOB:
DOB:
DOB:
Gender:
Gender:
Gender:
Gender:
DESCRIPTION OF INCIDENT
(The details of the incident should include WHO, WHAT, WHEN, WHERE, WHY and HOW, including a description of
injuries, if any, and the type of medical treatment provided. Use additional pages if necessary)
***Supplementary attachments shall NOT replace the narrative***
I do hereby attest that the information I provided is true and correct to the best of my knowledge.
________________________________________ |
___________________________________________ |
________________________ |
PRINT NAME |
SIGNATURE |
DATE |
4900 N. Lamar Blvd., 5th Floor East |
http://www.tjpc.state.tx.us |
Phone (512) |
|
Post Office Box 13547 |
Page 2 of 2 |
TDD (512) |
|
Austin, TX 78711 |
Revised 4/2010 |
Fax (512) |