Form TJJD-AID-001 "Incident Report Form" - Texas

What Is Form TJJD-AID-001?

This is a legal form that was released by the Texas Juvenile Justice Department - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest edition provided by the Texas Juvenile Justice Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form TJJD-AID-001 by clicking the link below or browse more documents and templates provided by the Texas Juvenile Justice Department.

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Download Form TJJD-AID-001 "Incident Report Form" - Texas

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T
EXAS
INCIDENT REPORT FORM
J
UVENILE
J
USTICE
Administrative Investigations Division
D
EPARTMENT
Fill out both sides of form and submit completed form and any additional documentation to:
Email: abuseneglect@tjjd.texas.gov
REPORTER’S INFORMATION
Form Completed By Name/Title
Phone #
Fax #
Email Address
First Person of Knowledge Name/Title
Phone #
Email Address
County Case ID #
County
Incident Date
Incident Time
LOCATION OF ALLEGED INCIDENT
Name of Department/Program/Facility
Type of Program/Facility
(check one):
Pre-Adjudication (Detention)
Post-Adjudication (Secure)
Address
City
State
Zip
Post-Adjudication (Non-Secure)
Probation
Administrator’s Name/Title
Phone
Fax
JJAEP
Day Reporting Program
LAW ENFORCEMENT NOTIFICATION
Law Enforcement Agency Name
Person Notified
Phone
Fax
Report Number
Date Notified
Time Notified
SERIOUS INCIDENTS --
Report to TJJD within 24 Hours
Attempted Escape
Attempted Suicide:
Referred for Mental Health Services?
Y
N
Escape
Reportable Injury:
Escape-Furlough
Restraint related?
Y
N
Youth Sexual Conduct
If yes, what type?
Mechanical
Physical
Chemical
Youth-on-Youth Physical Assault
Name
DOB
Age
Race
Height
Weight
Gender
Placing County
PID
Current Location of Youth:
M
F
Facility
Residence
Other
Name of Parent/Guardian
Phone
Date Notified
Time Notified
Parent/Guardian’s Address
City
State
Zip
ABUSE, NEGLECT, EXPLOITATION, OR DEATH
Report to TJJD and Law Enforcement within 24 Hours:
Report to Law Enforcement within 1 Hour and TJJD within 4 Hours
Death:
Exploitation
Suicide
Non-Suicide
Emotional Abuse
Sexual Abuse:
Verbal Abuse
Contact
Non-Contact
Neglect:
Serious Physical Abuse
(injury that requires medical treatment):
Medical
Supervisory
Restraint related?
Y
N
Physical Abuse
If yes, what type?
Mechanical
Physical
Chemical
Restraint related?
Y
N
If yes, what type?
Mechanical
Physical
Chemical
TJJD-AID-001 (11/15)
11209 Metric Boulevard, Bldg. H
P.O. Box 12757
www.tjjd.texas.gov
Page 1 of 2
Austin, TX 78758
Austin, TX 78711
P (512) 490-7230 or (512) 490-7126
T
EXAS
INCIDENT REPORT FORM
J
UVENILE
J
USTICE
Administrative Investigations Division
D
EPARTMENT
Fill out both sides of form and submit completed form and any additional documentation to:
Email: abuseneglect@tjjd.texas.gov
REPORTER’S INFORMATION
Form Completed By Name/Title
Phone #
Fax #
Email Address
First Person of Knowledge Name/Title
Phone #
Email Address
County Case ID #
County
Incident Date
Incident Time
LOCATION OF ALLEGED INCIDENT
Name of Department/Program/Facility
Type of Program/Facility
(check one):
Pre-Adjudication (Detention)
Post-Adjudication (Secure)
Address
City
State
Zip
Post-Adjudication (Non-Secure)
Probation
Administrator’s Name/Title
Phone
Fax
JJAEP
Day Reporting Program
LAW ENFORCEMENT NOTIFICATION
Law Enforcement Agency Name
Person Notified
Phone
Fax
Report Number
Date Notified
Time Notified
SERIOUS INCIDENTS --
Report to TJJD within 24 Hours
Attempted Escape
Attempted Suicide:
Referred for Mental Health Services?
Y
N
Escape
Reportable Injury:
Escape-Furlough
Restraint related?
Y
N
Youth Sexual Conduct
If yes, what type?
Mechanical
Physical
Chemical
Youth-on-Youth Physical Assault
Name
DOB
Age
Race
Height
Weight
Gender
Placing County
PID
Current Location of Youth:
M
F
Facility
Residence
Other
Name of Parent/Guardian
Phone
Date Notified
Time Notified
Parent/Guardian’s Address
City
State
Zip
ABUSE, NEGLECT, EXPLOITATION, OR DEATH
Report to TJJD and Law Enforcement within 24 Hours:
Report to Law Enforcement within 1 Hour and TJJD within 4 Hours
Death:
Exploitation
Suicide
Non-Suicide
Emotional Abuse
Sexual Abuse:
Verbal Abuse
Contact
Non-Contact
Neglect:
Serious Physical Abuse
(injury that requires medical treatment):
Medical
Supervisory
Restraint related?
Y
N
Physical Abuse
If yes, what type?
Mechanical
Physical
Chemical
Restraint related?
Y
N
If yes, what type?
Mechanical
Physical
Chemical
TJJD-AID-001 (11/15)
11209 Metric Boulevard, Bldg. H
P.O. Box 12757
www.tjjd.texas.gov
Page 1 of 2
Austin, TX 78758
Austin, TX 78711
P (512) 490-7230 or (512) 490-7126
STAFF-ON-YOUTH ALLEGATIONS ONLY
Name
DOB
Age
Race
Height
Weight
Gender
Placing County
PID
Current Location of Youth:
M
F
Facility
Residence
Other
Name of Parent/Guardian
Phone
Date Notified
Time Notified
Parent/Guardian’s Address
City
State
Zip
Name / Title
TJJD will not investigate these incidents; however, it is important that we collect
YOUTH-ON-STAFF ASSAULTS ONLY
this data. Please report all assaults on staff to local law enforcement and TJJD.
Name / Title
DOB
Race
Gender
M
F
Was the staff injured?
Y
N
If Yes:
Was medical treatment needed?
Y
N
Briefly describe any injuries:
Name
DOB
Age
Race
Gender
Placing County
PID
M
F
Name of Parent/Guardian
Phone
Date Notified
Time Notified
Parent/Guardian’s Address
City
State
Zip
DESCRIPTION OF INCIDENT
• THIS SECTION MUST BE COMPLETED. Supplementary attachments may not replace the narrative.
• The details of the incident should include who, what, when, where, why, and how, including a description of any injuries and the
type of medical treatment provided. Use additional pages if necessary.
• NOTE: If the first person of knowledge is not the person who is submitting this form, the first person of knowledge must attach a
signed, dated statement.
APPROVAL
I do he by attest that the information I provided is true and correct to the best of my knowledge.
Printed First and Last Name
Signature
Date
X
TJJD-AID-001 (11 5)
www.tjjd.texas.gov
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