Internal Investigation Form

Internal Investigation Form
Internal Investigation Form must be completed by Regional Operations Director or higher level management staff. All starred (*) sections MUST be completed in order for the form to be submitted.
Section I.

Event Location Information
Choose the State in which this investigation is taking place.*
Choose the Indiana Office Location in which this investigation is taking place.*
Choose the Virginia Office Location in which this investigation is taking place.*
Choose the Kentucky Office Location in which this investigation is taking place.*
Choose the Montana Office Location in which this investigation is taking place.*
Choose the Wyoming Office Location in which this investigation is taking place.*
Choose the Colorado Office Location in which this investigation is taking place.*
Please indicate if this investigation is related to a consumer or an employee.*

Consumer InvestigationEmployee Investigation
Section II.

Victim / Perpetrator Information
I. Victim(s) / Alleged Victim(s) Information*
II. Perpetrator(s) / Alleged Perpetrator(s) Information*
Section III.

Event Information
I. Event Category*
Incident Report (Non Behavioral) Category *
Colorado Incident Type*
Incident (Non Behavioral) - Mistreatment Abuse Neglect Exploitation Type *
Incident (Non Behavioral) - Criminal Activity Type *
Incident Report (Non Behavioral)- Death *
Incident Report (Non Behavioral) - Environmental Type *
Incident Report (Non Behavioral) - Medical Type *
Incident Report (Non Behavioral) - Medication Error Type *
Incident Report (Non Behavioral) - Staff Type *
Incident Report (Non Behavioral) - Other Type *
Behavior Incident Report Type*
Wyoming Critical Type*
Wyoming Non-Critical Type*
Montana Critical Type*
Montana Reportable Type*
Kentucky Incident Type*
Virginia Incident Type*
Employee Complaint Type*
Employee Investigation (Not Complaint related) Type*
Consumer Complaint Type*
Section IV.

Incident Details
Incident Report Number (If Applicable)
Location of Incident*
Date / Time Incident Occurred*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date / Time Incident Reported to Bridges:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name of Bridges Staff Incident was Reported to*
Date / Time Incident Reported to State (if required)

MonthDayYear
Date
Hour MinutesAM/PM Option
Please list any safety measures put into place immediately following Incident:
Required Staffing Ratio at Time of Incident (Example: 2 consumers to 1 staff = 2:1)
Actual Staffing Ratio at Time of Incident (Example: 3 consumers to 1 staff = 3:1)
Please enter a detailed description of the incident:*
Section V.

Witness Information
Please list the names of any individuals directly involved in the Incident*
Please list the names of any individuals present (before / during / after) whether directly involved or not:*
Section VI.

Evidence
Are written statements required for this investigation*

YesNo
Please direct any individual needing to provide a statement in regards to this investigation to the Bridges website Employee Portal. The Signed Statement for Internal Investigations Form is location in the "Employee Forms" section. (Please note: this form can be used by any individual it does not require the reporting party to be a Bridges employee).

The statement form can also be accessed at the following link:

https://form.jotform.com/92464457600155
Please list the name and relationship or title of EVERY individual for which a written statement is required. (Please note any one who was directly involved in the incident will need to provide a statement as well as all witnesses to the incident)
Total number of written statements required at completion of investigation*
Select any other evidence collected (select all that apply)*

Testimonial (Oral / Verbal Communication)Physical (Clothing, weapons, objects)Demonstrative (pictures, diagrams, maps)No Other Evidence Collected
Provide a summary of all Evidence Collected as selected above:*
Attach any pictures, diagrams or maps collected as evidence in regards to this investigation:

Cancelof
Section VII.

Final Findings
Based on all the information reviewed, it has been determined that the event(s) of this investigation is:*

Substantiated, the findings support the event as describedUnsubstantiated, the findings do not support the event as describedPartially Substantiated, the findings support part of how the event was described but not entirelyInconclusive, there not enough information to support substantiating or not substantiating the issue. Please include detailed information as to why the event is being deemed inconclusive as well as any action taken for future.
Please write detailed findings information indicating the following: Were there any rights were violated? (Include specific details as to whose rights and how violated)*
Please write detailed finding information indicating the following: Were services not provided or not provided properly (Include specific details as to what services, to whom and the issue with the services)*
Please write detailed finding information indicating the following: Were any agency policies and/or procedures not followed (Include specific details regarding what policy was violated and by whom)*
Please write detailed finding information indicating the following: Were any local, state, federal or other applicable regulations not followed (include specific details regarding regulation(s) violated and by whom)*
Write a summary of the findings including any pertinent information not previously listed in this section. *
Section VIII.

Resolution Information
Resolutions should be determined by a Director or Higher level management postion with the authority to make management and personnel decisions. (RM, RA, VP, ROD) Please note that all staff terminations and workers compensation situations as a result of an investigation require approval from Director of Risk Managment.
Please list a detailed summary of the resolution(s) to the event and how future occurrences will be prevented. This could include disciplinary actions, consumer support adjustments, medical treatments, retraining and other items. *
Name of Person Determining Resolution*

First NameLast Name
Title*
Section IX.

Corrective Action
Corrective Action Recommended*

YesNo
Describe all corrective actions developed and implemented as a result of this investigation. Include the name / title of the individuals responsible for implementation of each corrective action item along with the required dates of completion.
Corrective Action Details (Please enter information for ALL Corrective Action)*
Section X.

Completion
Date*

MonthDayYear
Date
Upon completion of the internal investigaton form the individual completing the form must sign their name and title below prior to submitting the form.
Signature*

Clear
Title of Person Completing Investigation*
Should be Empty:

Internal Investigation Form

Section I.

Section II.

Section III.

Section IV.

Section V.

Section VI.

Section VII.

Section VIII.

Section IX.

Section X.