Form Tjpc Ane 05 05 PDF Details

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.

QuestionAnswer
Form NameForm Tjpc Ane 05 05
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesTJPC-ANE-05-05, TYC, JJAEP, tjpc

Form Preview Example

TJPC-ANE-05-05

TEXAS JUVENILE PROBATION COMMISSION

INCIDENT REPORT FORM

Please complete BOTH sides and fax or e-mail this form and any applicable documentation to:

Texas Juvenile Probation Commission, ANE Investigation Unit, at (512) 424-6716

OR abuseneglect@tjpc.state.tx.us

If you have any questions, please contact the Commission at (512) 424-6700.

Form Completed By:

Title:

 

County Case ID#:

 

 

 

 

 

Phone: (

)

Fax: (

)

 

 

 

 

 

1ST Person of Knowledge:

Title:

 

 

 

 

 

Date of Incident:

 

Time of Incident:

 

 

 

 

 

Was the incident originally reported using the Commission’s Call-Line?

Yes

No

Date:

Time:

LAW ENFORCEMENT INFORMATION

Law Enforcement Agency:

Person Notified:

Date Notified:

Time Notified:

Incident Number:

Phone: (

)

Fax: (

)

ABUSE, NEGLECT, EXPLOITATION OR DEATH

(Check all that apply)

 

REPORT TO THE COMMISSION & LAW ENFORCEMENT WITHIN

 

REPORT TO THE COMMISSION WITHIN 4 HOURS & TO LAW

 

 

 

 

24 HOURS

 

 

 

 

 

 

ENFORCEMENT WITHIN 1 HOUR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emotional Abuse

 

 

 

 

 

 

Death

 

Suicide

Non- Suicide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verbal Abuse

 

 

 

 

 

 

Sexual Abuse

Contact

Non-Contact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Abuse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Restraint Related?

Yes

No

 

 

 

 

Serious Physical Abuse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, what type?

Mechanical

Physical

Chemical

 

Restraint Related?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, what type?

Mechanical

Physical

Chemical

 

 

 

Neglect Medical

Supervisory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exploitation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERIOUS INCIDENTS

– Report Within 24 Hours

 

 

 

 

 

 

 

 

 

 

 

(Check all that apply)

 

 

 

 

 

 

 

 

Attempted Suicide:

 

 

 

 

 

 

Youth on Youth Physical Assault

 

 

 

 

 

Referred for Mental Health Services?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Escape

 

 

 

 

 

 

Youth Sexual Conduct

 

 

 

 

 

 

Reportable Injury: Restraint Related?

Yes

No

If yes, what type?

Mechanical

Physical

Chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF INCIDENT

(specify ONLY the location in which the incident is alleged to have occurred)

Department/Program/Facility:

 

County:

 

 

 

Administrator:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

Phone: (

)

 

 

Fax: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-Adjudication (Detention)

 

 

 

Probation

 

 

 

 

 

 

Post-Adjudication (Secure)

 

 

 

JJAEP

 

 

 

 

 

 

 

 

Post-Adjudication (Non-Secure)

 

 

Day Reporting Program

 

 

 

 

 

 

 

 

 

ALLEGED VICTIM/JUVENILE INFORMATION

 

 

 

 

 

 

 

 

(A separate form must be completed for EACH alleged victim/juvenile)

 

 

 

 

 

Name:

 

 

Age:

DOB:

 

 

Gender:

Race:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PID:

 

 

 

Placing County:

 

Height:

 

Weight:

 

 

Is juvenile a TYC youth?

Yes

No

TYC #:

Current Location of Juvenile:

 

 

 

 

 

 

 

 

 

Facility

Residence

Other (specify location)

 

 

 

 

Name of Parent/Guardian:

 

 

 

Date Notified:

 

Time Notified:

 

 

Address (City, State & Zip Code):

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4900 N. Lamar Blvd., 5th Floor East

http://www.tjpc.state.tx.us

Phone (512)

424-6700

Post Office Box 13547

Page 1 of 2

TDD (512)

424-4000

Austin, TX 78711

Revised 4/2010

Fax (512)

424-6716

TJPC-ANE-05-05

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:

Re-assigned Resigned Suspended Terminated

Re-assigned Resigned Suspended Terminated

Re-assigned Resigned Suspended Terminated

Re-assigned Resigned Suspended Terminated

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)

424-6700

Post Office Box 13547

Page 2 of 2

TDD (512)

424-4000

Austin, TX 78711

Revised 4/2010

Fax (512)

424-6716