CCMS Restrictive Intervention Report

Please complete this form in full, providing all relevant and necessary detail to enable any investigation that may be necessary to take place fully and without unnecessary delay.

Client Name Client Name First Last
Date of Intervention Date of Intervention / DD / MM YYYY
Time of Intervention Time of Intervention : HH MM AM/PM
Duration of Intervention (in minutes)
Did the intervention take place at the client's home address?

Did the intervention take place at the client's home address? Yes No
Describe the location of intervention:
Incident background
Why did the incident occur?
Explain the circumstances leading up to the incident:
What actually happened?
Describe the strategies employed to attempt to de-escalate the situation and prevent the incident occurring:
Staff involved

This is the description of your section break.
How many care/support workers were involved?

How many care/support workers were involved? One Two Three Four
Name of care/support worker 1: Name of care/support worker 1: First Last
Name of care/support worker 2: Name of care/support worker 2: First Last
Name of care/support worker 3: Name of care/support worker 3: First Last
Name of care/support worker 4: Name of care/support worker 4: First Last
Witnesses
Were there any witnesses?

Were there any witnesses? Yes No Unknown
Name of witness: Name of witness: First Last
Phone number of witness:
Add another witness?

Add another witness? Yes No
Name of witness: Name of witness: First Last
Phone number of witness:
Details of Restrictive Intervention
Who did what?
Detail of restrictive intervention used:
Reasons for the use of restrictive intervention:
Detail of resolution:
Support provided following incident, and to whom:
Record any injuries and any medical attention required, and by whom:
Your name: Your name: First Last
Your phone number:
Your email address:
Your role:

Your role: Care/Support Worker Agency Staff Other (Please specify)
Responsible Case Manager:
An Investigation form must be completed within 7 days by the Case Manager
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / DD / MM YYYY
Time Time : HH MM AM/PM
Disclaimer

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CCMS Restrictive Intervention Report

CCMS Restrictive Intervention Report

Incident background

Staff involved

Witnesses

Details of Restrictive Intervention

An Investigation form must be completed within 7 days by the Case Manager