UL Sav ro3-y a ETE Health Services for Children with Special Needs, Ine. 1731 Bunker Hill Road, NE Washington, DC 20017 (202) 466-8483 Office of Qu: mpliance Evaluation and Patient Initial: Patient Medicaid #:_— UNUSUAL INCIDENT. RT, Part I - Reported By: |, Pereon first reporting Incident: ‘8. Title/Position: Youth Care Worker hon ‘b. Date/Time Reported: Month Q1_____Day07_Yr.2007___ Time 5:55 pm_ 2, Person Reporting Incident to HSCSN: ‘2, Title/Position: Case Manager ®, Phone F . Date/Time Reported: Month O7 Day 07 ‘Yr. 2007 ‘Time 635 pm 3. Administration or Office: Pari Il Type of facidents 4. Type of cident: Threatening comments 5. Date/Time of incident: Month 01 Day oD Yr 2007 ____ Time 555 pm_ 6 LocatiowPlace of incident: Atlas Unt 7. Peson (6) volved: eee Part IM -Details of Tacident: z 8. (What, How, Why): KEE told stafF that he was going to kill someone so that he can go to Oak ‘il. When NENG was being transported to secure he tld staff that he was going to Kil imsel. “re was placed in a safety smock and placed on direct observation to ensure his safety. Part IV Action (9) Taken & By Whom 9. . sat laced on direct observatc his safory, Part V - (for HSCSN Quality Management Department Use) 10. Gare Manager Receiving Report: 11 Roviowed By: Date/Time Reported: Month Day_____i Time 12, Reported to: Med, Director. Dieter or Team Leader. Giither Check or Specify Nama) Date/Time Reported: Month Yr ‘Time * Inecessary, attach separate sheet for additional pertinent documentation. Bsc -e52805 HSCSN 01004