A to Z Behavioral Services

Injury & Incident Reporting Protocol Acknowledgment Form

Dear Parent/Guardian,

At A to Z Behavioral Services, we are committed to maintaining a safe and structured environment for all clients and staff. While we take every precaution to ensure safety, injuries and incidents may occur. This policy outlines how we handle injuries, aggressive behaviors, and emergency situations, including when 911 is called. The information filled out in your intake form will be used in case of emergency.

1. Injury & Incident Reporting Process

If an injury or behavioral incident occurs during an ABA session, our staff will follow these steps:

  1. Assess & Address the Situation: Staff will provide first aid if necessary and ensure safety.
  2. Notify the Parent/Guardian: A parent/guardian will be informed as soon as possible after the incident.
  3. Complete an Incident Report: Staff will document the date, time, location, individuals involved, and a summary of the event.
  4. Provide a Written Report: A formal Incident/Injury Report will be given to the parent/guardian and kept on file.

2. Behaviors That May Harm Others

We strive to implement proactive strategies to prevent harmful behaviors, but in some cases, a client may engage in behaviors that pose a risk to themselves or others. These may include:


☐ Physical Aggression (hitting, kicking, biting, scratching)
☐ Self-Injurious Behavior (SIB) (head-banging, biting self, excessive scratching)
☐ Elopement (running away from the therapy area, leaving the premises)
☐ Property Destruction (throwing objects, breaking items, damaging property)
☐ Severe Emotional Outbursts (uncontrollable screaming, inability to de-escalate)

If such behaviors occur, staff will follow Crisis Management Procedures, which may include de-escalation techniques, behavior intervention plans, and parental notification.These are tailored to your child’s needs and the safety of everyone involved.

3. When 911 is Called

In rare cases, emergency medical services (EMS) will be contacted if:

  • The client sustains a serious injury (e.g., head trauma, severe bleeding, loss of consciousness).
  • The client is experiencing a medical emergency (e.g., seizure, breathing difficulty, allergic reaction).
  • The client exhibits uncontrollable aggression that poses an immediate danger to themselves, staff, or others.
  • The client elopes in a situation that creates significant safety concerns (e.g., running into traffic, getting lost).

In the event 911 is called:

  • Parents/guardians will be notified immediately.
  • A staff member will stay with the client until emergency responders arrive.
  • A detailed report will be completed and shared with the parent/guardian.
  1. Acknowledgment & Agreement


By continuing, you acknowledge that you have read and understandA to Z Behavioral Services’s Injury & Incident Reporting Protocol. You understand that:

  • All incidents will be documented and reported in a timely manner.
  • Staff will implement behavior intervention strategies to prevent harm whenever possible.
  • 911 may be called in the case of a medical emergency or serious safety concern. 
  • If I, nor my secondary contacts cannot be reached after two attempts each, 911/emergency services may be called
  • You will be notified of any injuries or incidents as soon as possible.


Final Statement

I acknowledge that I have received, read, and understand the Injury & Incident Reporting Protocol of A to Z Behavioral Services.

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