Pursuant to OAR 859-010-0005(11) and OAR 859-200-0020(9), an incident report is a report completed by a PSRB case monitor that describes any significant behavioral or mental health changes, serious violations of conditional release requirements, psychotropic medication refusals, or any other information that is relevant to an individual’s ability to be safely managed in a community setting. Serious incidents should be reported immediately to the Board via phone with a follow-up written account using this form.

Client Name:	Date(s) of Incident: Date of Report: Click or tap to enter a date.
Case Monitor:	Agency:
Level of care: Choose an item. How long at this level of care?	Enrolled in APD Services: ☐ Yes ☐ No Enrolled in ID/DD Services: ☐ Yes ☐ No Legal Guardian: ☐ Yes ☐ No
☐ PSRB monthly reports up to date	☐ PSRB prescriber notes up to date

Incident Type (check all that apply)
☐Significant change in mental status ☐Significant change in medical status ☐Relapse ☐Serious Violation of Conditional Release Plan	☐Verbal or Physical Aggression to Other(s) ☐Abscond ☐Medication Refusal ☐Other: Click or tap here to enter text.

Description of Incident and Factors Contributing to the Incident
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Summary of Interventions Used by the Treatment Team
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Client’s Response to the Interventions
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Treatment Team Recommendations/Results
☐Local Hospitalization (Psychiatric) ☐Local Hospitalization (Medical) ☐ Add/Increase monitoring, supervision, treatment ☐ Create Safety Plan	☐ Increased Level of Care/Step-up ☐ No Changes ☐ Revocation ☐Other: Click or tap here to enter text.
Describe: Click or tap here to enter text.

Describe Any Additional Resources Funding Necessary to Execute the Recommendations
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Please specify recommendations and include whether they are temporary or permanent (i.e., require a new Board order). If temporary, please provide information about how long they will be in place or under what conditions they will be removed.