Shelter Incident Report | Lantern Forms

HR Forms
Lantern Help Desk
Encounter Forms

Select Page

Lantern-New-Logov4

Shelter Incident Report

Report an incident at a shelter site

This form is only available to shelter sites.

Open it from the Encounter Forms page

Shelter Incident Report

For incidents at shelter sites. Follows the DHS incident reporting procedure (DHS-PB-2022-001) and the DHS-93 incident glossary.

1When & Where

2Incident Type

3People & Responders

4Details

5Reporting Status

Shelter(Required)

Report Prepared By(Required)

Preparer Name(Required)

Preparer Title(Required)

Preparer Email(Required)

A copy of the report and the DHS reporting deadlines are emailed here.

Incident Date(Required)

Incident Time(Required)

Hours

:

Minutes

AM/PM

Were staff notified at the time of the incident?(Required)

Yes

No

DHS requires the date and time staff were notified if it differs from the incident time.

Date Staff Were Notified(Required)

Time Staff Were Notified(Required)

Hours

:

Minutes

AM/PM

Incident Location(Required)

Onsite

Offsite

Specific Location(Required)

Where exactly it happened, e.g. unit 702, dining hall, front entrance, or the offsite address.

DHS Incident Type(Required)

From the DHS-93 glossary. If unsure which type or category applies, call SIU at (212) 361-5700.

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

DHS Incident Category(Required)

The priority level DHS assigns is shown in brackets (P1, P2 or P3).

Mandatory Incident Questions

DHS requires every question to be answered. If a question does not apply, answer No.

Were emergency services called?(Required)

Yes

No

Was an arrest made?(Required)

Yes

No

An arrest makes this a Priority 1 incident, whatever the category.

Was someone hospitalized?(Required)

Yes

No

Was the incident perpetrated by staff?(Required)

Yes

No

Was a weapon used?(Required)

Yes

No

Did the incident involve a minor?(Required)

Yes

No

Was ACS contacted?(Required)

Yes

No

Did ACS take a child to the hospital?(Required)

Yes

No

An ACS hospitalization makes this a Priority 1 incident.

Was a safety transfer offered?(Required)

Yes

No

Was a DV referral made?(Required)

Yes

No

Persons Involved

Name everyone involved, including staff. Link clients in CARES when you enter the report there.

Primary Client Involved

Sub Residents

Include Sub Residents

Unit / Bed #

Primary Client CARES ID

Primary Client's Role

Other Clients Involved

One per line: name, role (victim / perpetrator / witness) and CARES ID.

Staff Involved

One per line: name, title and role.

Other Witnesses

Emergency Responders

Which emergency services responded?(Required)

NYPD

FDNY

EMS

Other

Responder Names, Badge Numbers and Precinct / Unit(Required)

Hospital(Required)

Which hospital the person was taken to.

Additional Details for This Incident Type

Medical, Mental Health or Substance Use History(Required)

Required by DHS for deaths.

Repair Status or Expected Repair Date(Required)

Is an elevator out of service?(Required)

Yes

No

How Are Clients with Mobility Issues Being Assisted?(Required)

How Many Doses of Narcan Were Administered?(Required)

Please enter a number greater than or equal to 0.

Has the person been found?(Required)

Yes

No

Follow-up by Staff(Required)

Where and when they were found, or what staff are doing to locate them.

Staff Misconduct

Employee Status(Required)

Arrest

Termination

Suspension

Transfer

Under investigation - no action yet

Status of the Investigation(Required)

What Happened

Incident Description(Required)

A factual narrative in sequence: who, what, where and when. Name everyone involved, including staff, and note the source of all information.

Actions Taken and Resolution(Required)

What staff did and the current status, e.g. person located, repair scheduled, client returned from hospital.

Reporting Status

Priority 1: call SIU at (212) 361-5700 within 1 hour and enter the report in CARES within 4 hours (by noon the next day overnight, on weekends and holidays). Priority 2 and 3: enter in CARES within 72 hours.

Was SIU called?(Required)

Yes

Not yet

Not required (Priority 2 or 3)

Time SIU Was Called(Required)

Hours

:

Minutes

AM/PM

SIU Staff Spoken To

Has the report been entered in CARES?(Required)

Yes

Not yet

CARES Incident Number

Has the incident been recorded in the facility logbook?(Required)

Yes

Not yet