A copy of this form will automatically be emailed to the email address you enter below. You will also be able to print the results of this form on the next page after you press submit. Today's Date Report Completed by    E-Mail  Client name UCI   DOB                        Program Name Vendor Number                         Program Address City  Zip Code                    Telephone Date of Incident  Time of Incident                Type of Incident Location of Incident                   This Section for Abuse Incidents Only Perpertrator Name Relationship to Client                       Describe Incident: Were there any other individuals involved in this incident? No  Yes               If Yes please list names and titles: Was physical containment used?  No   Yes              Was the client injured?  No   Yes     If Yes please describe: Was medical treatment provided?  No   Yes    If Yes, please provide information: Date   Nature of Treatment  Medical Facility                       Name of Who Provided Treatment   Preventative action taken (if any): Indicate vendor action taken so far. For abuse incidents please submit SIR follow-up report indicating action after investigation by regional center, police and licensing is completed. Staff Training  Policy Revision  Administrative leave  Staff Termination Other:             Agencies Notified Person Contacted  Date Telephoned  Date Report Submitted  Date of Visit Regional Center Licensing (CCL or DHS) Police CPS/APS/ Ombudsman Parent/ Legal Guardian

CONFIDENTIAL CLIENT INFORMATION SAN GABRIEL/POMONA VALLEYS DEVELOPMENTAL SERVICES, INC. See California Welfare & Institutions Code, Section 4514