When and How to Write an Incident Report

An incident report is a formal document filed separately from regular session notes whenever an unusual or significant event occurs during a session. They exist to: (1) protect the client, the RBT, and the agency legally, (2) trigger appropriate clinical review, and (3) satisfy insurance and regulatory requirements.

Situations That ALWAYS Require an Incident Report

  • Injury to the client (any physical harm requiring first aid or more)
  • Injury to the RBT or other staff during session
  • Property damage caused by client behavior
  • Elopement — the client leaves the session location/safe area
  • Restraint use (physical, mechanical, or chemical via medication)
  • Medication error if the RBT administered or supervised medication
  • Allegation of abuse by client, family, or witness
  • Disclosure by the client suggesting abuse, neglect, or self-harm
  • Aggression toward another person resulting in contact
  • Self-injurious behavior at a severity above the documented baseline
  • Equipment failure affecting client safety

Situations That Do NOT Require an Incident Report

Expected behaviors that the behavior plan addresses — including planned extinction bursts, brief vocal protests, mild non-compliance, and documented programmed scenarios — go in regular session notes. The incident report is for the abnormal, not the routine.

The Standard Format

  1. Date, time, location of the event
  2. Names of those involved (use initials or client ID per agency policy)
  3. Antecedent: What was happening immediately before the event
  4. Description of the event: Factual, observable, chronological — no interpretation
  5. Consequence/intervention: What was done during and immediately after
  6. Outcome: Current status of all involved
  7. Notifications: Who was contacted and when (BCBA, parent, EMS, etc.)
  8. Follow-up needed: Medical, clinical, regulatory
  9. Reporter signature and date

Timing

Incident reports must be filed within 24 hours — ideally same-day. Delayed reports are clinically less useful and legally suspect. Most agencies have a tracked submission deadline; missing it can be grounds for disciplinary action.

Tone

Use neutral, professional language. "Client engaged in self-injurious behavior consisting of 12 head-strikes against the wall over 4 minutes" — not "client had a meltdown" or "everything was a disaster." The incident report may be read by attorneys, insurers, and regulators years later.