Form DCF-824 "Significant Event Report Form" - Connecticut

What Is Form DCF-824?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-824 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-824 "Significant Event Report Form" - Connecticut

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Connecticut Department of Children and Families
SIGNIFICANT EVENT REPORT FORM
DCF-824
4/16 (Rev.)
Page 1 of 3
NAME OF REPORTER:
RELATIONSHIP/AREA OFFICE/FACILITY:
DATE/TIME OF INCIDENT:
DATE/TIME REPORTED TO DCF RISK MANAGEMENT:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number
Date Case Last Closed:
Worker’s Name
Area Office/Facility
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NOTE: SIGNIFICANT EVENT AS DEFINED IN DCF POLICY 31-8-3 MUST BE REPORTED TO THE
OFFICE FOR RESEARCH AND EVALUATION/RISK MANAGEMENT
(DCF.RISKMANAGEMENT@CT.GOV)
(Phone: 860-560-7095) (Fax: 860-920-3050)
Connecticut Department of Children and Families
SIGNIFICANT EVENT REPORT FORM
DCF-824
4/16 (Rev.)
Page 1 of 3
NAME OF REPORTER:
RELATIONSHIP/AREA OFFICE/FACILITY:
DATE/TIME OF INCIDENT:
DATE/TIME REPORTED TO DCF RISK MANAGEMENT:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number
Date Case Last Closed:
Worker’s Name
Area Office/Facility
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NAME OF CHILD:
DATE OF BIRTH:
CHILD’S PRIMARY LANGUAGE:
SEX:
AGE:
RACE:
LEGAL STATUS:
DATE/TIME DCF NOTIFIED OF INCIDENT:
DATE/TIME POLICE NOTIFIED OF INCIDENT:
I - DCF CASE STATUS
Active
Closed
No prior involvement
Link Number:
Date Case Last Closed:
Worker’s Name:
Area Office/Facility:
NOTE: SIGNIFICANT EVENT AS DEFINED IN DCF POLICY 31-8-3 MUST BE REPORTED TO THE
OFFICE FOR RESEARCH AND EVALUATION/RISK MANAGEMENT
(DCF.RISKMANAGEMENT@CT.GOV)
(Phone: 860-560-7095) (Fax: 860-920-3050)
Page 2 of 3
abduction of a child in DCF custody or care
an incident involving group runaways from one facility
an incident of a single person runaway, when the child is 13 or older, who:
has not returned within one hour OR
has returned with any injury OR
who is suspected of being the victim of a crime while away from the foster home or facility
a significant disturbance involving a youth at a DCF operated or licensed facility
allegation of a serious crime by an adult authorized by the Department to be
responsible for
the care of a child (including a DCF employee, licensed foster/adoptive parent or an employee
of a licensed or contracted provider)
arrest of any child or youth in the care or custody of DCF
a serious injury suffered by a DCF employee in the course of his/her duties
a serious threat to a DCF employee in the course of his/her duties resulting in
notification to
law enforcement (Human Resources, Workplace Violence Report.)
suicide or suicide attempt by a child in DCF custody or care, a child with an open DCF case
deterioration of care or other important agency function due to some disruption of the physical
plant or environment within a DCF licensed or operated setting. (e.g., fire, natural disaster,
failure of electronic equipment, other safety conditions, etc.)
any call for Police or Emergency Services intervention
an injury to a child or youth in DCF care or custody which required medical attention
any event that may affect the health, welfare or safety of the residents at a DCF licensed,
contracted or operated facility, such as
strikes
major disturbances
public health issues
bomb threats
any event related to DCF that is likely to result in media coverage.
STAFF OR OTHERS INVOLVED, IF APPLICABLE:
Page 3 of 3
II - OTHER CHILDREN LIVING AT THE SETTING AT TIME OF INCIDENT (N/A for facilities)
Name
D.O.B.
Living situation after incident
IlI - NOTIFICATION MADE TO:
Family
Name
Police
Name
Member
Attorney
Name
Hotline
Name
Area
Name
Facility
Name
Office
Worker
Other
Name
IV-DESCRIPTION OF INCIDENT
TITLE
SIGNATURE OF PROVIDER, OFFICE DIRECTOR, SUPERINTENDENT, OR DCF DESIGNEE
AREA OFFICE/FACILITY
DATE
Page of 3